I made the questions that I can’t find the answer in red→ ask the instructor in class time to find
the answer
D(dose) divided by H(have) times Q(quantity)
Week 1
1. Nursing process and 11 needs assessment guide. Posted on e-centennial
Human needs are ranked on an ascending scale according to Maslow
● Physiological needs
● Safety and security needs
● Love and belonging needs
● Self-esteem needs
● Self-actualization
2. Clinical reasoning: A thought process used to assess a client’s evolving situation and health care
concerns, gather data, and make decisions to solve problems within a particular clinical context
to achieve better client outcomes.
3. Distinguish clinical reasoning from clinical judgment and critical thinking
Critical thinking: a systematic process that facilitates the nurse and client to make more informed
decision. The skill needs to use relevant information, knowledge, and communication
technologies to support evidence-informed nursing practice.
● Recognize key words
● Recognize who is the client: what is client’s condition
● Ask yourself what is happening
● Critical: see what option you have available
● Eliminate the options
Clinical reasoning: similar process, involves many of the same strategies to address patients and
client issue, but it also focuses on the alternative generated. Complex process using cognition
and discipline specific knowledge to analyze patient info and evaluate what is important
Clinical judgement: a process of evaluating alternatives and concluding about best approach- the
outcome of thinking
4. Role of critical thinking and clinical reasoning in nursing process
5. The purposes and legal and ethical considerations of documentation in health care. (kozier,
462)
● Communication: Clear, concise, relevant, and accurate documentation provides continuity of
care and increases the probability of quality health care.
● Planning client care: use by each health care provider to plan care
● Accountability: Their documentation must be accurate, relevant, timely, and complete
● Auditing for quality assurance
● Education and research
● Legal documentation
Limitation
● Time consuming
● Remove human connection
● High cost
6. What is documentation? CNO
Documentation — whether paper, electronic, audio or visual — is used to monitor a client’s
progress and communicate with other care providers. It also reflects the nursing care that is
provided to a client. It is aIterative (changes each time but repetitive)
7. Purpose of charting or documentation, indicate main one
8. Make a list of “roles/guideline” (do and don’t) to follow for charting. What must be included
in your charting entries?
Do
Do not
first name, last name and role
Miss a line after you are done
Document (communication, accountability, and
security)
Example:
Date: 2019/Jan/21
Note: Patient vomited blood. Nurse manager aware, MD informed and new orders made, patient
will continue to monitor---------------------------------------------------------Niousha Tavakoli, PRN
Know abbreviations commonly used for documentation and reporting (lab).
9. Type of documentation method
A. Sources-oriented: Each person or department makes notations in a separate section or sections
of the client’s chart. Source-oriented records are convenient because health care providers
from each discipline can easily locate the forms on which to record data, and it is easy to trace
the information to a specific discipline. The disadvantage is that information about a particular
client problem is scattered throughout the chart, so it is difficult to find chronological
information on a client’s problem and progress.
a. Narrative charting: It consists of written notes that include routine care, normal findings, and
client problems. The information has no right or wrong order, although a chronological order is
recommended and frequently used. Narrative documentation is being replaced by other
systems, such as charting by exception and focus charting.
B. problem-oriented medical record (POMR) or (POR): data are arranged according to the
problem the client has rather than according to the source of the information. The advantages
of POR are (a) it encourages collaboration; and (b) the problem list is in the front of the chart,
which alerts health care providers to the client’s needs and makes it easier to track the status of
each problem. The disadvantages are (a) health care providers differ in their ability to use the
required charting format; (b) it takes constant vigilance to maintain an up-to-date problem list;
and (c) repetitive because assessments and interventions that apply to more than one problem
must be repeated. POR has fur components; database, problem list, plan of care, progress
notes (SOAP)
C. The assessment, problem, intervention, evaluation (ADPI) model: This system consists of a
client care assessment flowsheet and progress notes.
D. Focus charting (DAR- data action response): it is intended to make the client’s concerns and
strengths the focus of care. Three columns for documenting are usually used: (a) date and time,
(b) focus, and (c) progress notes (see the example at the end of this section).
E. Computerized documentation: use to manage huge volume of information required in
contemporary health care
F.
Charting by exception: a documentation system in which only significant findings or
exceptions to norms are recorded by using flowsheets as much as possible
G. Soap (subjective, objective, assessment, planning)
H. The key elements of a change-of-shift (SBAR) report. (Murray, 80) The SBAR is a
communication tool commonly used during change-of-shift reports to promote and maintain
effective communication between the health care team when discussing a client’s condition
and progress.
1. Situation: include your name, place you work at, person’s first name and last name, describe
the problem and concern
2. Background: state briefly the patient medical history/any recent changes/emergent issue and
treatment date and its effectiveness
3. Assessment of any issue/symptom: onset, provoking/palliating, quality region/radial, severity,
treatment, understanding/impact on resident and values
4. Recommendation: state what you would like to see done
10. Discuss the purpose of incident reporting and the nurse responsibility in promoting a culture
of safety for quality client care. (promotion of quality, not punishment)
Documentation (Kozier, 471)
A. Long-term care: The nurse usually completes a nursing care summary at least once a week for
clients requiring skilled care and every 2 to 4 weeks for those requiring intermediate care.
Summaries should address the following:
● Specific problems expressed by clients and/or familie
● Mental health status
● Activities of daily living (ADLs)
● Hydration and nutrition status
● Elimination status
● Safety measures needed
● Medications
● Treatments
● Preventive measures
Vital signs are taking once a month
The Minimum Data Set (MDS) for assessment and care screening must be performed within 4
days of a clients admission to a long-term care facility and reviewed every 3 months
B. Acute care
C. Home care: Health care providers often document in client-held records that remain at the
residence. Health care providers may access critical information through the use of voicemail,
wireless devices, and laptops, which enhances their ability to care for their clients and maintain
accurate and current records.
Week 2
1. Describe the differences and similarities between a group and a team.
● A group is a number of individuals assembled together or who have some unifying relationship.
Groups could be all the parents in an elementary school, all the members of a specific church,
or all the students in a school of nursing because the members of these various groups are
related in some way to one another by definition of their involvement in a certain endeavour.
● A team, on the other hand, is a number of individuals who work closely together toward a
common purpose, are accountable to one another and sharing responsibility. Not every group
is a team, and not every team is effective. Teams have defined objectives, ongoing
relationships, and a supportive environment and are focused on accomplishing specific goals.
Teams are essential in providing cost-effective, high-quality care. As resources are expended
more prudently, teams must develop clearly defined goals, use creative problem solving, and
demonstrate mutual respect and support.
● A group of people does not constitute a team. A team is a group of interdependent individuals
who seek out opportunities to combine their expertise to achieve common goals: Collaboration
2. Compare and contrast types of teams. exercise in Yoder-Wise book p 354
● Manager-led team: The manager is the team leader and controls the agenda, decisions,
direction, and outputs of the team.
● Self-managing team: The manager sets the overall direction and defines the goal and outcome
for the team. The members of the team determine the direction, strategies, and focus of the
team to achieve the goal.
● Self-directed team: The manager identifies the outcome, and the team members determine the
direction, strategies, methods, and focus to achieve the outcome. Often, these teams function
in quality improvement initiatives to address quality challenges and opportunities.
● Self-governing team: This team is a collection of individuals who come together to create
something new or address an opportunity or challenge. The team determines appropriate
membership, sets its own direction, defines the outcomes, and then manages team
performance and outcomes
3. Explore key aspects of team development. Yoder-wise p. 356
It is essential to establish ground rules for the team as well as build trust in the team, both of which
are essential to collaboration, creativity, and achieving the desired goals.
● “In” and “out” groups
● Power and control
● Using developing, being appreciated for skills and resources
● Ground rules
● Trust
Phase of group development
4. Describe characteristics of effective and ineffective teams.
5. Describe the qualities of an effective team member.
● Adaptable: Inflexibility does not work in teams. Being rigid in thinking or behaviour is
destructive to both the individual and to the team.
● Collaborative: Collaboration is more than cooperation. It means each person brings something
to the project that adds value to the team and supports the creation of synergy.
● Committed: Commitment is a passion in the face of adversity to take actions and make things
happen. It is the passion to do whatever it takes to accomplish the team objectives.
● Communicative: Communication should happen early and often. Frequency of interaction with
other team members, talking with them and sharing thoughts, ideas, and experiences: these
are the activities that support teamwork.
● Competent: Competence translates as someone who is quite capable and highly qualified and
does the job well.
● Dependable: Team members who are dependable follow through and do what they have
agreed to do well, without prodding or delay.
● Disciplined: Discipline is doing what you really do not want to do so you can accomplish the
goals you really want and includes paying attention to the details in thinking, in emotions, and
in the actions you take.
● Enlarging: Helping a teammate advance or grow into a better person or a good team member;
helping teammates advance the team; believing in your teammates before they believe in
themselves are examples of value-added.
● Enthusiastic: Enthusiasm focuses on becoming a highly energetic team member who has a
positive attitude and believes that the team, together, can be better than anyone dreamed they
could.
● Intentional: The team and its members have a purpose for themselves and for the team. Every
action counts and is meaningful. The focus is on doing the right things in each moment and
following through with these actions to their logical conclusion.
● Mission conscious: Each team member has a sense of purpose and mission that drives all
thoughts, ideas, and actions to do what is best for the team and the cause.
● Prepared: Being prepared translates into preparation for every meeting and event and begins
with a thorough assessment of what is needed, aligning the appropriate work with the
appropriate effort, addressing the mental aspects of the right attitude, and being ready to take
action.
● Relational: The ability to be connected to other members of the team, to be in a relationship
with them, is the core of being relationship-oriented. These relationships and the mutual
respect upon which they are built create cohesiveness on the team.
● Self-improving: As a team member, you strive to continually grow and reflect, both routinely
and periodically, on how well each venture of assignment went and what you could have done
better. This is a process of self-reflection.
● Selfless: Putting others on the team ahead of yourself through being generous to team
members, avoiding “playing politics,” showing loyalty toward team members, and valuing
interdependence among team members over the value of being independent are all examples
of selflessness.
● Solution-oriented: Do not be consumed with all of the problems associated with the
endeavour; rather, focus on finding the solutions; think about what is possible.
● Tenacious: Being tenacious means giving your all, with determination, and refusing to stop until
the goal has been accomplished.
6. Identify factors that influence group dynamics and team building. Yoder p. 358
Synergy: Effective teams are ones in which people work together to produce results and achieve a
common goal that could not have been achieved by any one individual.
Note: Each member of the team must understand the reason the team is together, determine what
he or she wishes to accomplish (as delineated by defined goals
and objectives), and express his or her belief in both the value and feasibility of the goals and tasks.
Note: It can not occur if one team member become a self-proclaimed expert who has the right
answer and/or when people refuse to communicate.
Dualism means that most situations are viewed in terms of two opposing sides or parts (right or
wrong, yes or no), limiting the broad spectrum of possibilities that exists between.
7. Explore the role of conflict in teams and factors that hinder effective communication. Yoder p.
365- table 19-4 and box 19-4
● Stress:
● Communication barrier: (distractions, inadequate knowledge, poor planning, difference in
perception, and emotions and personality)
● Communication pitfalls: (giving advice, making others wrong, being defensive, judging the other
person, being patronizing, giving false reassurance, asking “why” question, and blaming others
8. Review guidelines for effective communication to support team functioning. Yoder-Wise
Exercise 19-4 p. 364
● Approach each interaction as though the other person has no knowledge of effective
communication. Assume responsibility for creating the sender-receiver rhythm.
● Share your thoughts and feelings. Be self-revealing.
● Use casual conversation or “small talk”: it can be important to relationships, particularly when it
is light and humorous. It balances deep, meaningful talk.
● Acknowledge, praise, and encourage the other person; doing so is supportive and brings life
and energy to the relationship.
● Present messages in a way that the other person can receive them.
● Take responsibility for any problem or issue you have with another, and speak about it as your
problem or issue also.
● Use language of equality even when position titles are not of the same level.
9. Describe concepts of collaboration and collaborative practice. Yoder p. 488
● Collaborative practice is “an inter-professional process for communication and decision making
that enables the separate and shared knowledge and skills of the care providers to
synergistically influence the client/patient care provided”
● Collaboration has been described as a complex, voluntary, and dynamic process with
underlying concepts of power, interdependency, sharing, partnership, and process Through
collaboration, interdisciplinary teams should be able to accomplish more than individuals
working alone or in tandem. Care for patients could occur more seamlessly between
institutions and communities, health promotion and illness prevention could be included for all
patient encounters, health care providers could be able to stay informed of new evidence, and
health outcomes could be improved
10. Describe the impact of team functioning on interprofessional collaboration and sharing
information within the "Circle of Care" in the delivery of healthcare.
An interprofessional team comprises “different healthcare disciplines working together towards
common goals to meet the needs of a patient population.
Team members divide the work based on their scope of practice; they share information to support
one another’s work and coordinate processes and interventions to provide a number of
services and programs”.
11. Construct a team contract as a basis for effective collaboration.
Week 3- part 1
1. Define the teaching and learning process
o Teaching: a system of activities intended to produce learning
o Teaching-learning process: is intentionally designed to produce specific learning and involves
dynamic interaction between teacher and learner. Each participant in the process
communicates information, emotions, perceptions, and attitudes to the other. The teaching
process and the nursing process are much alike
o Learning: a change in human disposition or capability that persists and that cannot be
accounted for solely by growth.
o Compliance: individual’s desire to learn and to act on the learning
o Adherence: reflect the client’s engagement in the learning process and willingness or ability to
follow a recommended treatment regimen
2. Discuss the different learning theorist and domain when planning client-centered care
Behaviourism: a theory based on learning as reflected in changes in behaviour
● Learning is based on the learner’s behaviour
● Stimulus and response
● Conditioning (reward-punishment)
● Positive reinforcement
● Theorists: Skinner, Pavlov, Bandura
● Nurses applying behaviouristic theory will do the Following: provide time and opportunities for
learners to solve problems by trial and error, select teaching strategies that evoke the desired
behaviours, praise the learner for correct behaviour and provide positive feedback at intervals
throughout the learning experience, provide role models of the desired behaviour
Cognitivism: depicts learning as a complex cognitive activity that is largely a mental, intellectual, or
thinking process. (understanding)
● Based on perceptions and personal characteristics
● Social, physical and emotional context of learning
● Developmental readiness, teacher-learner relationship and environment are key factors
● Theorists: Piaget, Lewin, Bloom
● Nurses applying cognitive theory will do the following: provide a social, emotional, and physical
environment conducive to learning, encourage a positive teacher–learner relationship, select
multisensory teaching strategies, recognize that personal characteristics have an impact on
learning, develop teaching approaches to target different learning styles, adapt teaching
strategies to the learner’s developmental level and readiness to learn, select teaching strategies
that encompass the cognitive, affective, and psychomotor domains of learning
Humanism: focuses on both the cognitive and the affective qualities of the learner. Learning is selfmotivated, self-initiated, and self-evaluated. (making it eaningful)
● nurses applying humanistic theory will do the following: recognize the importance of the nurse–
client relationship on learning, encourage learners to identify their own learning needs and
establish goals, encourage active learning by serving as a facilitator, mentor, or resource for the
learner, provide information or assist learners to access and evaluate new, relevant information
● Theorists: Maslow, Rogers
●
Social Constructivism: This theory argues that people create their own understandings by
integrating their previous experience/knowledge with new learning, within specific contexts,
including crucial social contexts
● Social constructivism is holistic, it is “a passionate approach, involving the whole person:
thought, emotion and action”
● Focus on cognitive, affective & psychomotor qualities of the learner
1. Knowledge is constructed by learner
2. Built on previous knowledge and learning
3. Values socio-cultural influences & meaning
4. Experience-based; thoughts, emotions & actions
5. Holistic, focuses on learning process
6. Learning from social actions and collaborating
Domains of learning? Cognitive (understanding) , psychomotor (doing) , affective (feeling, make a
connection)
○ The cognitive domain includes six intellectual skills, from simple to complex, beginning with
knowing, comprehending, and applying.
○ The affective domain involves five major learning categories: (a) feelings, (b) emotions, (c)
interests, (d) attitudes, and (e) appreciations.
○ The psychomotor domain includes motor skills, such as giving an injection, and also reflects a
development hierarchy of skills, reflecting increasing independence in performance of the skill.
3. Explore teaching strategies related to different learners. (Kozier p.513)
● Explanation or description
● One-to-one discussion
● Answering questions
● Demonstration
● Discovery
● Group discussions
● Practice
● Printed and audiovisual materials
● Role-playing
● Modelling
● Computer-assisted learning programs
(from learning circle)
○ Definition: kozier, p. 502
● Andragogy is the art and science of teaching with a special focus on adults.
● Pedagogy is concerned with all teaching and learning strategies regardless of age,
although this Greek term refers to teaching children.
● Geragogy is focused on the learning of older adults.
● Three major developmental stage factors associated with clients’ readiness to learn
include physical, cognitive, and psychosocial maturation.
● Learning
○ 3 years: diagram, short
○ Adolescents: divide into short sessions
○ 75 years: clear sentences
4. Identify factor that facilitate and inhibit learning. (Kozier, p.504-506)
5. Explore teaching and learning as a component to the nursing
6. Compare the teaching process with learning process. From powerpoint:
o
▪
▪
Assessment: Collect data – client’s health strengths & deficits
Health history
Physical assessment
Diagnosis: knowledge deficit about ibuprofen r/t newly prescribing newly prescribed drug s/b
can you tell me about it?
o Analysis: Identification of health Needs/problems:
▪ Nursing diagnoses Prepare care plan:
▪ SMART goals/expected outcomes
▪ select interventions
o Implement nursing interventions
▪ Knowledge, skill, judgment
o Evaluate client outcomes
▪ based on achievement of goal criteria
7. Discuss practice recommendation in facilitating client-centered learning.
o
Week 3- part 2
8. Identify sources of drug information in Canada. (Note: This information can also be found
through the “Related Links” with the Medication “Decision Tool” as noted on the CNO
website)
● The Compendium of Pharmaceuticals and Specialties Is published annually by the Canadian
Pharmacists Association
● Is a comprehensive (but not entirely complete) list of the pharmaceutical products distributed
in Canada
● Also contains other helpful information for health care professionals
● Information voluntarily submitted by pharmaceutical manufacturers
● Over the counter (otc)
o With pharmacist only (behind the counter)
o Within a pharmacy (on the shelf)
o In any store without professional supervision
● Prescription only
o Less potential for abuse
o Potential for abuse
● Restricted access:
o Controlled drugs
o Narcotics (opioids)
9. Discuss Canadian drug legislative acts controlling drug use and restricted drugs of abuse.
(review the PowerPoint presentation posted on ecentennial)
Two Acts form the underlying foundation for the drug laws in Canada:
Food and Drugs Act and the Food and Drug Regulations are the primary pieces of legislation
concerning drugs (prescription and over-the-counter (OTC) drugs) in Canada and has two main
purposes:
● To protect the consumer from drugs that are contaminated, adulterated or unsafe for use
● To address drugs that are labeled falsely and those with misleading or deceptive labeling (focus
is on appropriate advertising and selling)
Controlled Drugs and Substances Act (1997) and Narcotic Control Regulation addresses the
possession, sale, manufacture, disposal, production, import, export and distribution of certain
drugs, their precursors and other substances classified as controlled.
● Controlled substances may only be dispensed by healthcare providers to clients suffering from
specific diseases or illness. Applies to narcotics (it is stored in locked, secured, containers),
nurse should count them and co-sign when take one, and when disposing it, nurse need to have
a witness
● Co-signing with another nurses
● The RCMP (per Health Canada) are responsible for enforcing the CDSA.
● Describes eight Schedules and the factors that determine which schedule a controlled
substance should be under are based on potential for abuse and the ease with which illicit
substances can be manufactured in illegal labs in Canada (and the usefulness of the substance
as a therapeutic agent)
● (examples: Schedule I contains heroin and cocaine (considered the most dangerous drugs);
Schedule II contains marijuana; Schedule III contains amphetamines and LSD; Schedule IV
contains barbiturates that can also have therapeutic uses)
● CDSA also provides for the non-prescription sale of certain codeine preparations (example:
Tylenol #1 for sale only by pharmacists)
Non-prescription Drugs
● Over-the-counter (OTC) drugs are available to consumers without a prescription
● There are three categories of non-prescription drugs that limit their sale
o Restricted access drugs are physically “kept behind the counter” in the pharmacy to be
controlled by the pharmacist (e.g. insulin, Tylenol #1) to ensure individuals are not selfdiagnosing and get counseling by the pharmacist
o Drugs only available through sale in a pharmacy, so a pharmacist is available to answer any
questions about the drug (e.g. anti-histamines and ulcer medications)
o Drugs available to be sold at any retail outlets, variety stores (e.g. acetaminophen, ibuprofen)
● Advantage:
▪ Convenient
▪ Effectively self-treat many minor ailments
▪ Good for short-term
▪ Enables health care professionals to spend more time with the “really sick”
▪ Financial gains to HC system
● Disadvantage:
▪ Relieves symptoms but not underlying cause
▪ Delays seeking medical care until very ill
▪ Misuse of product
▪ May have interactions with other drugs
▪ Lack of medication teaching
10. Outline the 3 principles of authority, safety and competence based on the CNO Medication
Practice Standard. IMPORTANT
http://www.cno.org/en/learn-about-standards-guidelines/standards-and-guidelines/
○ Authority: Nurses must have the necessary authority to perform medication practices.
● Registered Nurses and Registered Practical Nurses require an order for a medication
practice when: a controlled act is involved, administering a prescription medication,
or it is required by legislation that applies to a practice setting.
● Describe when an order is required
● Nurses accept orders that are: clear, complete, appropriate
○ Competence: Nurses ensure that they have the knowledge, skill and judgment needed to
perform medication practices safely.
● ensure their medication practices are evidence- informed
● assess the appropriateness of the medication practice by considering the client, the
medication and the environment
● know the limits of their own knowledge, skill and judgment, and get help as needed,
and
● do not perform medication practices that they are not competent to perform.
○ Safety: Nurses promote safe care, and contribute to a culture of safety within their practice
environments, when involved in medication practices.
● seek information from the client about their medication, as needed
● provide education to the client regarding their medication
● collaborate with the client in making decisions about the plan of care in relation to
medication practices
● promote and/or implement the secure and appropriate storage, transportation and
disposal of medication
● promote and/or implement strategies to minimize the risk of misuse and drug
diversion take appropriate action to resolve or minimize the risk of harm to a client
from a medication error or adverse reaction
● report medication errors, near misses or adverse reactions in a timely manner
● collaborate in the development, implementation and evaluation of system approaches
that support safe medication practices within the healthcare team
11. Identify the essential parts of a medication order.
7 essential parts of a drug order
● Patient's name
● Date and time the order is written
● Name of the drug to be given
● Dosage of the drug
● Route
● Frequency
● signature of person writing order
in addition:
clinical indicator and note
Abbreviations:
● Enteral – by gastrointestinal eg) Oral (po = per os) by tablets, capsules or liquids
● Oral- most common
● Sublingual – Under the tongue, absorbed into the blood
● Buccal – medication is held in the mouth against the mucous membranes of the cheek
● Rectal
● Nasogastric or gastrostomy tube
● Topical
● Dermatological- skin
● Instillation and irrigation-body cavities such s urinary bladder, eye, ear, nose, rectum,
vagina
● Inhalation
● Parenteral – by injection –
● Subcutaneous: hypodermic
● Intramuscular: IM
● Intravenous: IV
● Intradermal: ID
● Note: IV and sublingual are the fastest for absorption. Oral is the slowest
- What is a “scored” pill? Medication suitable for splitting
- EC (enteric coated- you can’t cut or crush it, if it happens patient can develop ulcer),
XL (extra-long, extra-large), CR (controlled release), SR (sustained release)
What are different types of medication orders?
1. Stat order: the medication is to be given immediately and only once
2. Single order: one-time order (lorazepam 1mg before surgery)
3. Standing order: may or may not have a termination date, may be carried out indefinitely
(multiple vitamins daily)
4. RPN order: as-needed order, permit the nurse to give a medication when the client require it
base on nurse’s judgment
5. Protocol order: set of criteria and order under which a medication is to be administered
(heparin protocols often used in hospital setting)
6.
What are some concerns about communicating a medication order? The nurse should always
question the prescribing health care professional about any order that is ambiguous, unusual
(e.g., an abnormally high dosage of a medication), or contraindicated by the client’s condition.
(Kozier, p.806)
12. Discuss the developmental considerations for older adults that can affect medication
administration (Adam, p.61)
● Older adult
13. Discuss informed consent, the role of the nurse in meeting patient learning needs about
medications. Kozier, P.811, 1212
● Principles of Teaching/Learning
● Learning and factors facilitating and/or inhibiting learning
● Teaching and Teaching Strategies
● Comparison of Teaching and Nursing processes
What should the nurse tell the client about diet and medications?
14. calculation for single and 24-hour medication dosing
15. Discuss the role of the PN in delegating to UCP for medication administration in the long-term
care setting http://www.cno.org/en/learn-about-standards-guidelines/educational-tools/askpractice/delegation/
● Delegation: a process by which a health care professional who has legal authority to perform a
controlled act transfers that authority to an unauthorized person.
16. Apply the nursing process to the safe administration and documentation of medications using
the CNO Practice Standards for Medications. Adam, Chapter 5
o Nursing Process:
▪ Assessment [subjective, physical, and diagnostic tests
▪ Nursing diagnosis
▪ Planning
▪ Implementation
▪ Evaluation
o What actions should the nurse take for a client who has difficulty swallowing pills? Oral
medication procedure
o Name and explain the factors that affect medication action.
o Process for giving Medications – Following the “5 Rights”. All basic nursing fundamentals
textbooks discuss the “5 Rights”, but Kozier now outlines “10 rights”. Why do you think the
extra “Rights” have been adopted?
o Outline the steps for the 5 fundamental “Rights”. Where do the additional “Rights” fit in? The
CNO has recently adopted “Principles” rather than “Rights” for Medication
Administration. Why is this? Kozier p.814
● Right client: can you please confirm your name and date of birth?
● Right medication
● Right dose
● Right time
● Right route
● Right client education
● Right documentation
● Right to refuse: explain benefits, come back another time, inform and document it
● Right assessment
● Right evaluation
o What is the nurse’s role when medication error has occurred?
16. Discuss the role, limitation and responsibility of the PN in dispensing medications.
o Dispensing medication
o What are 4 pertinent questions that the nurse must consider before dispensing? – why are
these questions most relevant?
17. Explain the difference between a direct order and a directive
● direct order: client specific
● directive: implemented for a number of clients when specific clinical conditions and specific
circumstances are met
18. starting a new medication, what would you like to know? (reason for use, what are the side
effect? Reaction with other medication? How often do I take it? Is there an expiry date? Would
might be an allergic? Cost? Dosage? Where to get it? How to take? Food/diet interaction?
Route? How do I know if it’s working? How long do I take it for? Overdose/underdoes? What if I
miss a dose?
● As a nurse you need to know all the information about the medication
19. Rule of the nurse related to medication
● Nursing is interrelated to the other health care professions, including physicians and
pharmacists
● Medication is prescribed and administered collaboratively with appropriate health care team
members, dependent on data collection and accurate assessments
● Nurses prepare and administer medications using Standards to ensure patient safety
● Regulations vary according to settings (hospital, long-term care, home care)
● Requires knowledgeable critical thinking to make professional judgments and decision-making
● Patient safety is your top priority
From learning circle
1. What should the nurse do when medication errors occur?
● Call physician, charge nurse
● Notify family (POA)
● Assess VS (time, pain, LOC)
● Follow up- assess
● Document- incident report (near-misses and actual incidents)
2. CPS- compendium of paramedical and specialties
● All medication information (MOA, address effect)
● Updated yearly
●
3.
●
●
4.
Have all info about meds in year facility
Difference between dispensing and administering
Dispensing: if patient is going home, you can give medication to he/she
Administering: giving patient his/her meds right now
3 checks: check med before you take out, check med after take out, and check med before
administration
Week 4- ACUTE/CHRONIC ILLNESS, STRESS & INTEGRATING A PALLIATIVE
1. Differentiate between acute and chronic illness.
a. Illness: A personal’s physical, emotional, intellectual, social, developmental, or spiritual
functioning is thought be diminished. Highly personal state and subjective. It is the response an
individual has to a disease.
b. Disease: An alteration in bodily functions resulting in a reduction of capacities or a shortening
of normal lifespan. It is characterized by identifiable sign and symptoms.
c. Etiology: It is the causation of a disease. e.g. age, nutritional status, occupations. E.g. what are
etiologic of lung cancer? Smoking, unsafe factory work.
d. Acute illness: A disease that has a rapid onset, lasts a relatively short time, and is self-limiting,
you may or may not need to seek medical attention
i. Onset- rapidly
ii. Duration- short time (1-2 WEEKS)
iii. Recovery: full recovery
iv.
Stages
1. Stage 1: experiencing symptoms – e.g. pain, bleeding, swelling, fever, or difficulty with
breathing. Person uses OTC meds for self-healing. If not resolved then next stage.
2. Stage 2: assuming the sick role – validating this by not going to school or work. If not resolved
then next stage.
3. Stage 3: seeking medical care – physician or other HCPs validate the illness.
4. Stage 4: assuming a dependent role – accepts diagnosis and treatment and may enter the
hospital.
5. Stage 5: achieving recovery and rehabilitation
e. Chronic illness: a disease that requires continuing management over a long period-years or
even decades. HIV, cancer, and heart disease
- Range from mild to sever
- Some are characterized by remission and exacerbation
- What do the terms exacerbation and remission mean? During periods of remission, the person
does not experience symptoms, even though the disease is still clinically present. During
periods of exacerbation, the symptoms reappear. These periods of change in symptoms do not
appear in all chronic diseases.
2. Define the term “life-limiting illness”.
-
Examples of life-limiting: cancer, tumor, and MI, HIV, DEMENTIA
Def: Any illness, acute or chronic, that is likely to shorten or “limit” a person’s life. (may also be
called life-threatening) illnesses.
People with a life limiting illness can benefit from a palliative approach early in the disease
process.
3. Describe the four common trajectories (patterns) of dying and the unique challenges
associated with each. Murry. P.4
Each decline reflects changes in the person’s function and abilities, specifically changes in:
(document how family want to
- Ambulation – ability to move around
- Participation in activities
- Personal care
- Eating and drinking
- Cognitive functioning
Four common trajectories
- Sudden death- MI, Stroke, accident (10% of population)
- Steady decline- cancer (20% of the population), you know that you will die in a few months or
years – 6 months
- Stuttering decline (the roller coaster): chronic obstructed pulmonary disease , organ failure,
- Slow decline – Parkinson, Alzheimer
- (stuttering decline and slow decline - 70% of the population die this way)
- Label and draw line graphs below to depict the 4 trajectories of dying. (pattern of decline)
Describe the challenges for the individual and the family with each of the trajectories.
4. Discuss the impact of life-limiting illnesses and life transitions on an individual, family and
care providers. Not important
- See and reflect on the Ethics Touchstones in Murray p. 4, 5 & 9.
5. Explain the CHPCA “Square of Care” Model and implications for nursing practice.
- Why was a model developed? Who benefits from the Square of Care Model? To help ensure a
consistent, quality approach to care that addressed all the needs.
- Nurses can use it as a visual reminder to follow each step in the process of providing care, and
to address or consider of the common issues.
6. Compare the CHPCA “Six Steps of Providing Excellent Hospice Palliative Care” to the steps of
the Nursing Process.
- Assessment, information sharing, decision-making, care planning, care delivery, confirmation
- Is there anything in the 6 Steps of providing care that implies it can only be considered for
palliative care? Or is this process relevant for any type of care? Explain your reasoning.
7. Identify the eight “Common Issues” in the process of providing care to individuals and families
with a life-limiting illness.
- Disease Management- primary diagnosis, prognosis
- Physical- pain, LOC, safety, aids, fluid, wound, habits
Psychological- personaity, behaviour, depression, anxiety, fear
Social- cultural values, believe, practice, relationship, goal
Spiritual- meaning, value, beliefs, practice
Practical- ADL, dependent, pets, financial
End of life/Death Management- gift giving, life closure, rites, ritual, funeral
Loss and Grief- loss grief, anticipatory
8. Identify current barriers in accessing hospice and palliative care in Canada. Murray 19-22
- Belief of Ineligibility
- Insufficient training for HCPs
- Taboos and fear of talking about Death and Dying
- Lack of clear prognosis (maybe on year or more down the road), especially with a non-cancer
diagnosis, COPD
- Undeserved groups
- Elderly
- Children
- People with physical or developmental disabilities
- People who identify as LGBTQ
- People with mental illness
- Homeless people
- People in rural or remote areas, indigenous
-
9. Describe illness behaviours and the unique needs of the patient with acute illness and chronic
illness.
o What are “Illness behaviours”? (describe)
o How do you behave when ill and what factors affect these behaviours?
o Many factors affect illness behaviours (try to list 10)
o age, gender, family values, socioeconomic status, culture, educational level, and mental status.
The commonly recognized sequence of illness behaviors
10. Identify physiological, psychological and cognitive indicators of stress? Important
- What is stress? Stress is a condition in which the person experiences changes in the normal
balanced state
- Assessing for sign and symptoms of stress: cognitive, physiologic and physiologic
physical
o Dilation of pupils to increase visual perception
o Diaphoresis (sweat production) to control elevated body
o heat caused by increased metabolism
o Increased heart rate and cardiac output to transport nutrients including
oxygen and byproducts of metabolism more efficiently as well as increase
blood flow to active muscles
o Paling of the skin as a result of constriction of peripheral
blood vessels
o Increased retention of sodium and water to increase circulating blood
volume (as a result of the release of mineralocorticoids)
o Increased rate and depth of respiration to augment the availability of oxygen
o Reduction in urinary output to preserve circulating Volume
o Mouth dryness
Psychologic
Cognitive
o Decreased intestinal peristalsis, resulting in possible constipation and
flatulence. In some cases, people experience increased peristalsis, resulting
in diarrhea.
o Increased muscle tension to prepare for rapid motor activity or defense.
o Elevation of blood glucose, caused by the release of glucocorticoids and
gluconeogenesis.
o anxiety
o Fear: an emotion or a feeling of apprehension aroused by impending or
seeming danger, pain, or other perceived threat.
o anger
o depression
o Structuring: the arrangement or manipulation of a situation so that
threatening events do not occur. For example, a nurse can structure or
control an interview with a client by asking only direct, closed questions.
o self-control (discipline): assuming a manner and facial expression that
convey a sense of being in control or in charge, no matter what the situation
is.
o Suppression: consciously and willfully putting a thought or feeling out of
mind: “I won’t deal with that today. I’ll do it tomorrow.” This response
relieves stress temporarily but does not solve the problem.
o Fantasy: likened to make-believe.
many sources of stress (give an example of each)
o internal: originated within a person. eg. An infection or feelings of depression
o external: originated outside the individual, eg., a move to another city, a death in the family, or
pressure from peers
o developmental: occur at predictable times throughout an individual’s life. eg. At adolescent
(choosing a career; sexual attractions); At Young Adulthood (leaving home; rearing children;
continuing education)
o situational: unpredictable and can occur at any time during life e.g. Death of significant other,
getting or losing a job, or an acute illness
3. Discuss the potential impact of stress on the nursing student, especially in relation to the
clinical experience, and strategies for managing stress. P.1451
4. Discuss the lived experience of an individual and/or family experiencing stress related to
illness. Kozier, 233
“Depending on the illness trajectory, the stress response of an individual may be different than the
response of the family.” Do you agree or disagree with this statement? Why? Explain
-
Review the levels of anxiety and associate to anticipated manifestations in the illness trajectories.
How can the nurse modify plans of care based on awareness of stress responses and levels of
anxiety?
With regards to loss of autonomy - Nurses need to support the client’s right to self-determination
and autonomy by providing them with sufficient info to participate in decision making and
maintain feeling of control (by explanation, accommodate the client’s lifestyle, and active
listening).
Individual
● Individual experience behavioral and emotional
changes
● changes in lifestyle, self-concept, and body
image
● Becoming irritable and lack of energy or desire
to interact with others
● Vulnerable to loss of autonomy
● Illness may change the client’s body image or
physical appearance
● Individual may require to change his/her diet,
activity, exercise, rest, and sleep
-
Family
● Impact on family depends on:
o The member of family who is ill
o Seriousness and length of the illness
o Cultural and social customs the family follows
● Role changes
● Task reassignments and increased demands on
time
● Increased stress because of anxiety about the
outcome of the illness for the client and conflict
about new responsibilities
● Financial problems
● Loneliness as a result of separation and pending
loss
● Change in social customs
Anxiety – a big current and common issue often discussed in the media
common reaction to stress; subjective
state of mental (psychological) uneasiness, apprehension, dread, foreboding or a feeling of
helpless relate to an impending or anticipated unidentified threat to the self or significant
relationship
at conscious, subconscious or unconscious level
Four levels of anxiety: Mild, moderate, sever and panic p.1442
1.
What level is best for performance and learning? Why? Mild, because it prompts
a person to seek information and ask questions.
Is anxiety different than fear? How? Different in 4 ways
The source of anxiety may not be identifiable; the source of fear is identifiable.
-
I.
II.
III.
2. Anxiety is related to the future, that is, to an anticipated event. Fear is related to the past,
present, and future.
3. Anxiety is vague, whereas fear is definite.
4. Anxiety is the result of psychological or emotional conflict; fear results from a specific physical
or psychological entity
5. Describe standardized assessment and screening tools used to determine whether a person
would benefit from the integration of a palliative approach into care. See the assessment and
screening tools in the Murray textbook. Do you see any of these in your clinical placement?
a. Gold standards framework prognostic indicator guidance (GSF-PIG)- determine whether the
person might benefit from palliative approach being integrated into their care.
i. Step 1: surprise- would we be surprised if the person dies in the next 6 months
ii. Step 2: general indicator- life-limiting illness with comorbidities, limited ROM, progressive
weight loss, sentinel event (fall)
iii. Step 3: specific indicator- cancer, renal failure, dementia
b. Supportive and palliative care indicators tool (SPICT)- a screening tool developed to help
identify people at risk of deteriorating or dying in the near future, and to determine whether
they might have supportive or palliative care needs that should be addressed. Use this tool
assess any person any person who is living with a progressive life-limiting illness, is entering
residential care, or whose health is suspected to be decline
6. Explore the role of the nurse in using therapeutic communication to promote an empowering
nurse-family partnership. not required reading p.234-235
Review this model from the RNAO BPG “Supporting and Strengthening Families through Expected
and Unexpected Life Events”
Coping can be adaptive or maladaptive:
o Adaptive coping helps the person to deal effectively with stressful events and minimizes the
distress associated with them
o Maladaptive coping can result in unnecessary distress for the person and others associated
with the person or stressful event
o Effective coping results in adaptation; Ineffective coping results in maladaptation
Although coping behaviour may not always seem appropriate, the nurse needs to remember that
coping is always purposeful
o The nurse develops plans in collaboration with the client and significant support people, when
possible, according to the client’s state of health, level of anxiety, support resources, coping
mechanisms, and sociocultural and religious affiliation.
o The overall client goals for persons experiencing stress-related responses are as follows:
Decrease or resolve anxiety
Increase ability to manage or cope with stressful
events or circumstances
Improve role performance
8. Explain the therapeutic use of nonpharmacological methods to promote, maintain or restore
emotional well-being. Murry, p.118
Murray writes about a “COMFORT BASKET”. What are your thoughts on this idea?
*sleep deprivation/sleep pattern disturbance is a current issue where research is growing – what
information can you find which shows a correlation with sleep and stress and illness?
- Effective coping techniques are healthier ways of looking at and dealing with illness (e.g.
assertiveness, training, cognitive reframing, problem-solving skills, social supports)
- They are many, varied and can be taught
- A nurse is in a key position to assess patients’ ability to cope, educate patients about coping
skills, or provide referrals to patients to learn healthier ways of looking at and dealing with
illness
- Relaxation techniques, stress management and supportive education should be part of the care
of the patient with a medical condition, regardless of the medical diagnosis
- Although medical procedures may extend or promote life, they often take a toll on the patient’s
physical state because of the high degree of anxiety they evoke
- The following have all been shown to affect a patient’s recovery positively:
● Educating the patient regarding the specific medical treatment
● Referring the patient to community support groups (or systems)
● Teaching patients more effective coping skills that take into consideration patient’s values,
preferences, and lifestyle
● Focusing on a patient’s strengths and reinforcing coping skills that work (e.g. playfulness,
participation in hobbies, relaxation techniques
- There is growing evidence that psychotherapy can help people endure medical illness
- Beneficial psychotherapy approaches include:
● Cognitive-behavioural psychotherapy
● Guided imagery, biofeedback, acupressure, and hypnosis
● Psychodynamic psychotherapy
9. Using a case study, apply the nursing process, including establishing priorities in nursing care,
to develop a nursing care plan for a client and/or family experiencing stress due to illness.
10. What are some methods of coping with stress:
◦ Problem-focused coping: Try to improve the situation by making changes, “Fix-it” mentality to
take some action
◦ Emotion-focused coping: Try to discuss and share thoughts and feelings, Not focused on “fix-it”
for situation BUT emotional distress is relieved by acknowledgement
◦ Short-term coping: reduce stress to a tolerate limit temporarily but re ineffective way e.g. using
alcoholic beverage
◦ Long-term coping: can be constructive and realists e.g. talking with others, changing lifestyle
◦ Adaptive
◦ Maladaptive
Palliative: managing life
Learning circle: palliative care
- Assessment: use GSF, to assess people who are aging, has a life limiting illness, entering
residential care
Read assessment and Management of Pain in the Elderly (search it on the google and look at the
document. It has multiple choice practice as well)
Week 5: Inflammation, Infection & Fever
Lemore chapter 12
Review Kozier et al Case study #34 (p.925 in 4thed) .
Complete the critical thinking questions prior to coming to class (remember, you can refer to
case study answers through MyNursingLab if assistance is required, but it is better for your
learning to try independently first!)
Background review (look at Path notes too!)
Definition:
a) Pathogen: Organisms that can cause disease, Must bypass the body's defenses
i)
Bacteria, viruses
ii)
Fungi, intracellular organisms
iii)
Multicellular animals
b) Infection: What is an infection? Is the effect of a organism in the body
c) Causes of Infection:
i)
Bacteria – eg. norovirus ( inadequate hand hygiene)
ii)
Virus – eg. rhinoviruses,influenza,hepatitis,herpes, and HIV.
iii)
Fungi – eg. yeasts, moulds, and Candida albicans
iv)
Parasites- eg. protozoa, helminths(worms) and arthropods ( mites, fleas,ticks)
v)
Rickettsia & Chlamydia– eg.
vi)
Mycoplasma - e.g. penicillins
Types of infection:
d) Colonization: the presence of organisms in body secretions or excretions in which strains of
bacteria become resident flora but do not cause illness
e) Carrier: a person hosting an infectious pathogen, who shows no signs of the disease, but could
transmit the infection to others.
f) Local infection:organism enters the body and remains confined to a specific location, signs: edema,
pain, erythema, warth, functional impairment
g) Systemic infection: increase in size of lymph nodes, fever, loss of appetite, fatigue, leukocytosis ,
malaise, ….
h) infections—infection spreads to several sites and tissue fluids, typically through the circulatory
system
i) Nosocomial infection: occur in health care facilities, including hospitals, nursing homes, doctors’
offices, and dental offices.
j) Chain of infection IMPORTANT and intervention for each link. Kozier, p.887-888
i)
*Apply the Mrs. Cortez in Kozier Ch. 34 case study and the Mr. Fields posted case study on
ecentennial)- know the 6 link
1) Reservoir
2) Infectious Agent
3) Portal of exit
4)
5)
6)
k)
i)
1)
2)
Portal of entry
Mode of transmission
Susceptible host
Defences against infection:
Non-specific (2)
Anatomical & physiological barriers: vaccine
Inflammatory response (itis):
(a) cardinal signs- H.E.L.P.S (heat, erythema, loss of function, pain, swelling)
l) Antibiotic: Natural substance produced by bacteria that kills other bacteria
m) Bactericidal agent: Kill bacteria
n) Bacteriostatic agent: Slow the growth of bacteria
o) Probiotic supplement: help to prevent diarrhea that comes with Probiotic supplement
p) Pseudomembranous colitis: inflammation of colon, cause diarrhea (very watery), abdominal
cramping, dehydration and losing electrolytes, losing appetite
q) Acquired resistance: Occurs when pathogen develops gene that survives longer or grows faster.
r) Through maturation
i)
Antibiotics destroy sensitive bacteria
ii)
Insensitive (mutated) bacteria remain
iii)
Mutated bacteria multiply with less competition
iv)
Mutations random, occur during cell division; may harm or help the bacteria
v)
Mutated bacteria multiply
vi)
Bacteria may pass on resistance gene to others
s) Broad-spectrum antibiotic: Effective for a wide variety of bacteria
t) Narrow-spectrum antibiotic: Effective for narrow group of bacteria
u) Secondary infection: occur when too many host flora are killed by an antibiotic
i)
Host flora normally prevent growth of pathogenic organisms
v) Opportunistic: Take advantage of suppressed immune system
w) Inflammation (acute: last less than 1-2 weeks), (chronic: slower in onset, occurring over months or
years)
x) Stage of fever; onset or chill phase (heat loss< heat production)-keep the patient warm, give warm
fluid, plateau phase- treat to remove pyrogen , defervescence stage (heat loss> heat production)
give cool cloth, limiting activity, pt get dehydrated you would give fluid
y) Superinfections:Pathogenic microorganisms have chance to multiply, bacteria goes away and
come back -not a resistance bacteria
i)
pt may have yeast infection, vaginal infection
z) Opportunistic—Take advantage of suppressed immune system
i)
Signs and symptoms include diarrhea, bladder pain, painful urination, or abnormal vaginal
discharge
aa) Photosensitivity: sensitive to light, ex.tell pt to use sunglasses
bb) Blood dyscrasias- for example thrombocytopenia→ signs: nose bleeding, blood in stool, light
headache
cc) Peak and trough level: taking medication in its therapeutic level
dd) Nephrotoxicity: damage to the nerve- Tingling and numbness, cognitive impair
What are the factors that increase susceptibility to infection? (explain how the factors
contribute to susceptibility - and give an example of each)
1. Age- newborns and older adult
2. immune status- vaccination
3. Heredity- deficit in serum immunoglobulins
4. level of stress
5. nutritional status- ability to synthesize antibiotics can be impaired
6. current medical therapy- radiation treatments for cancer
7. Obesity- decrease blood flow to skin and underlying tissue
8. smoking- impairing tissue oxygenation
9. existing disease processes- Examples are chronic pulmonary disease, which impairs ciliary action
and weakens the mucous barrier; peripheral vascular disease, which restricts blood flow; chronic
or debilitating diseases, which deplete protein reserves; and immune system diseases, such as
leukemia and aplastic anemia, which alter the production of WBCs
10. previous surgery- scar tissue has reduced blood supply, interfering with delivery of leukocytes,
oxygen, and nutrients.
Why should we be concerned about wiidespread use of antibiotics?
- Antibiotics do not create mutations
- Resistance not caused by, but is worsened by, overprescription of antibiotics
· Results in loss of antibiotic effectiveness
-
Only prescribe when necessary
Long-time use increases resistant strains
Healthcare associated infections (HAIs) often resistant
Prophylactic use appropriate in some cases to prevent infection (e.g., dental procedure for person
with prosthetic heart valve)
Nurse should instruct patient to take full dose
Selection of an Antibiotic
– Use of culture and sensitivity testing ideally done first*, but may not be practical or needed
– To provide effective pharmacotherapy
– To limit adverse effects
Host factor influencing choice of antibiotic:
– Immune system status
– Local condition at infection site
– Allergic reactions
– Age
– Pregnancy
– Genetics
Study guide
1. Describe the use of isolation precautions in the hospital setting and in the home care setting
according to CNO Practice standards for “Infection Prevention and Control”.
Compare the different types of isolation under the following headings. – review from week 1 PNUR125
(What precautions have you seen in your clinical placement so far this semester?)
Example (type
of infection)
Airbornenuclei
smaller
than 5
microns
Contact
Dropletdroplets
larger than 5
microns
Reverse
measles,
varicella
(including
disseminat
ed zoster),
and
tuberculosi
s
gastrointestinal,
respiratory,
skin, or wound
infections;
colonization
with
multidrugresistant
bacteria;
such illnesses
are diphtheria
(pharyngeal);
pertussis
(whooping
cough);
mumps;
influenza,
viral
For patient
who is
immunoco
mpromised
specific enteric
infections,
such as with C.
difficile or
norovirus;
enteric
infections,
such as with
enterohemorr
hagic E. coli
O157:H7,
Shigella,
and hepatitis A
virus in clients
who are
diapered
or incontinent;
respiratory
syncytial virus,
parainfluenza
virus, or
enteroviral
infections in
infants and
young
children; and
highly
contagious
skin infections,
such as
herpes simplex
virus,
impetigo,
pediculosis,
and scabies.
pneumonia,
scarlet fever
in infants and
young
children; and
pneumonic
plague
Gloves
Yes
Yes
Yes
Gown
yes
If provide
direct care
Yes
Mask
N95
yes??
And eye
protector
If patient needs
to leave the
room, what
should be
done?
Place
surgical
mouth on
client’s
mouth
Limit
movement of
the client
outside the
room.
Private room
Place
surgical
mouth on
client’s
mouth
Private
room
Hand
Washing
-
Always yes
Handwashing must be performed:
Before and after administering medication
Before handing food or drink
Before and after PPE
After contact with body substances, specimens, or soiled items.
PPE should be use when:
Contacting with blood, secretions, body fluid and there is a risk that thous will penetrate the nurse’s
clothing
Nurses who come in contact with infection should:
Contact their primary care physician or occupational health department
Assess the risk of transmitting the agent
Know their immune state
2. Apply the nursing process (establishing priorities in nursing care) in the prevention and
control of inflammation, infection and/or fever.
Assessment
Subjective:- any history of above susceptibility factors
- status of immunization
- past infections
- medications that impact
- treatments that have punctured skin
- nutritional status
- Stress
Objective:
What are the local responses to infection? Same as inflammation
What are the systemic responses to infection?
- fever
- fatigue
- weakness
headache
- nausea
Relevant diagnostic (Lab) tests:
Culture and sensitivity:
- Examination of specimen for microorganisms
- Grown in lab and identified
- Tested for sensitivity to different antibiotics
- Bacteria may take several days to identify
- Viruses may take several weeks to identify
- Broad-spectrum antibiotics may be started before lab culture completedthey can cause pseudomembranous colitis
What is the significance of an elevated WBC? Decreased WBC?
Elevated: present of bacteria,
Decreased: body is immunocompromised (hiv) and viral
In “Cultures for C & S”, what does “Positive Cultures” mean?
Culture: bacteria
Sensitivity: antibiotic that can kill the bacteria
Positive culture: they found a culture
What is the significance of “Sensitivity”? Specific antibodies or medication
CRP: ( C- Reactive Protein which is a diagnostic marker of infection that
can be measured in the blood. Blood levels of CRP increase dramatically
with serious bacterial infection and sepsis making this marker a useful
early indicator of systemic infections ( pg. 286- Lemone Textbook)
ESR
Diagnosis
a)infection
b)inflammation,
c) fever
d) pain
a) Risk for infection – (REMEMBER – with “Risk for…” diagnosis statement,
there are no actual “shown by” findings to include in the NDx statement
a. Risk for infection r/t immunosuppression
b. Risk for infection r/t inadequate primary defenses secondary to
impaired skin, injured tissue, dehydration…etc – identify the CAUSE
(etiology) of the risk for infection
b) Acute Pain (left ankle) r/t left ankle edema and erythema secondary to
sprained ankle s/b states “ankle hurts 7 out of 10”, unable to weight
bear, grimacing on movement
a. Chronic pain r/t inflamed joints secondary to arthritis s/b states “knees
aching 4 out of 10”, moaning, decreased mobility
c) Hyperthermia r/t physiologic response to infection s/b T39.5C
Planning
r
Implementation
interventions:
Know the
how, what &
when for each
Recommendation routine practice BOX 34.3 KOZIER
BREAK THE CHAIN OF INFECTION
Nursing intervention for fever
Monitor vital signs at least every 2 hours if the patient is critically ill.
- Assess skin colour, temperature, and other physiological signs associated
with fever.
What nursing
interventions
prevent
nosocomial
infections?
-
-
-
-
Monitor white blood cell count, hematocrit value, and other pertinent
laboratory reports for indications of infection or dehydration.
Remove any excess blankets during the plateau and defervescence phase
(when the patient feels warm), but provide extra warmth during the
onset phase (when the patient feels chilled).
Provide adequate nutrition and fluids (e.g., 2500–3000 mL per day, if not
contraindicated) to meet the increased metabolic demands and prevent
dehydration.
Measure intake and output.
Reduce physical activity to limit heat production, especially during the
defervescence stage.
Administer antipyretics (drugs that reduce the level of fever), if this is
part of the patient’s treatment plan. (Note:More and more agencies are
recommending the administration of antipyretics only if the patient is
uncomfortable with the fever or has risk factors that limit the ability to
tolerate the increased BMR—as a result of evidence of the beneficial
effects that a fever has on leukocyte function and shifting practices to
“support the fever.”
Provide oral hygiene to keep the mucous membranes moist.
Reduce the temperature of the room, administer antipyretic medications
as prescribed, promote frequent rest period,provide additional fluid
intake
Risk for infection (Lemore, p, 281)
1. Assess the wound for specific manifestations of infection, including
purulent drainage, foul odor, and delayed healing. The normal inflammatory
response can indicate infection and, on occasion, mask its presence.
2. Evaluate complete blood counts for adequate WBC response.
Leukocytosis may indicate infection or healthy response to injury
and protection from infection. Immune-impaired patients may not
respond with increased WBCs; manifestations of inflammation may
be diminished in those individuals.
3. Monitor vital signs at least every 4 hours. In response to the
inflammatory process the temperature rises, usually in the range of
37.2°C (99°F) to 38.2°C (100.9°F). A temperature of 38.3°C (101.0°F) or
above indicates infection. Fever is usually accompanied by increased
heart and respiratory rates.
4. Apply dry or moist heat to the affected area for no longer than 20
minutes several times a day. Monitor the temperature closely to prevent
burns and further damage to the affected area. Heat increases the
circulation of blood to and from the inflamed tissue. Time is limited to
prevent burns.
5. Provide and encourage fluid intake of 2500 mL/day as allowed. Teach
the purpose and importance of hydration to promote blood
flow and nutrient supply to the tissues and also dilution and removal of
waste products and heat from the body.
6. Ensure adequate nutrition. Adequate nutrition enhances the function
and production of T cells and B cells, which are important in the immune
response.
7. Use good hand hygiene techniques consistently. Hand hygiene removes
transient microorganisms and is the best mechanism to prevent the
spread of infection to a susceptible person.
8. Use aseptic technique when providing wound care. Using sterile gloves
and aseptic technique helps prevent further contamination of the wound
and the spread of infection to other patients
Healthcare associated- infections
(1) avoiding prolonged bed rest, (2) encouraging patients to take
deep breaths, (3) providing adequate fluids, (4) providing regular toileting
schedules with good hygiene, and (5) avoiding use of invasive
devices such as indwelling catheters unless medically necessary.
How can we support the defences of a susceptible Host? (Kozier, p.909)
· HYGIENE Maintaining the intactness of skin and mucous membranes ensures a barrier against
microorganism entering the body. In addition, oral care, including flossing teeth, reduces the
likelihood of an oral infection. Regular and thorough bathing and shampooing remove
microorganisms, and the dirt that contains them, that can cause an infection.
· Nutrition: A balanced diet enhances the health of all body tissues, helps keep skin intact, and
promotes skin’s ability to repel microorganisms. Adequate nutrition enables tissues to maintain
and rebuild themselves and helps keep the immune system functioning well.
· Fluid: An adequate fluid intake permits a fluid output that flushes out the bladder and urethra,
removing microorganisms that could cause an infection. Adequate hydration also helps maintain
the natural barriers since dehydrated skin or mucous membranes have breaks through which
microorganisms can enter.
· Adequate sleep is essential to health and to renewing energy.
· Stress Excessive stress predisposes people to infections. Nurses can assist clients to learn stressreducing techniques.
· Optimizing Tissue Oxygenation and Blood Flow Optimizing blood flow allows sufficient
numbers of leukocytes to reach a given tissue; these are key cells for reducing the number of
microorganisms locally. Adequate tissue oxygenation will promote production of adenosine
triphosphate (ATP) for use by the leukocytes and either replacement or strengthening of the tissue.
Stopping smoking, ensuring adequate hydration, managing pain, reducing stress, avoiding obesity,
and correcting anemia are all strategies that promote blood flow and tissue oxygenation.
· Glycemic Control Uncontrolled glucose levels place the client at increased risk for infection.
Maintaining perioperative glycemic control such that that blood glucose is kept at less than 10
mmol/L is recommended to reduce the risk of surgical site infection Clients with diabetes need to
be taught to monitor their blood glucose levels and follow appropriate diet, exercise, and
medication strategies for controlling their diabetes.
· Immunizations: have dramatically decreased the incidence of infectious diseases. It is
recommended that immunizations begin shortly after birth and be completed in early childhood,
except for boosters.
3. Associate nursing interventions to the clinical manifestations and stages of a fever.
- How can the effects of a fever be controlled? (know the phases and appropriate interventions for
each phase. Fevers are common and most of us have had to treat a fever at some point (either your
own fever or a significant other. How do these nursing interventions compare to what you may
already have used in the past or had “common” knowledge of?) (Kozier, p.634) and ready 887-888
3. Describe delirium and associated causes of delirium, including infection, inflammation and
fever. (See box on Lifespan considerations in Kozier and Murray p. 133-138)
- What is delirium? An acute state of confusion that presents as a sudden, sever change in person’s
cognition, affecting their awareness, attention, thinking, perception, an subsequently, their
behaviour
- Why might delirium be frightening for the person or family?
- How would you explain to the family what is happening? In a family conference
- Clinical manifestations of infection and fever can vary throughout the lifespan and may present
atypically through behaviour changes. The most common cause of delirium at the end of the life is
medication. Metabolic insufficiency resulting from organ failure is the second most common cause
Common causes of delirium in the palliative setting:
● D- Drugs, dehydration and depression
●
●
●
●
●
●
●
E- Electrolyte imbalance, endocrine disorders, alcohol or drug abuse or withdrawal
L- Liver failure
I - Infection - urinary infection, pneumonia, sepsis
R- Respiratory problems (hypoxia), retention (urinary or constipation)
I- Increased intracranial pressure
U- Uremia - urinary issues (renal failure), undertreated pain
M- Metabolic disease, metastasis to the brain, medications, malnutrition
4. Explain the Confusion Assessment Method (CAM) tool for assessing delirium. (Murray, p. 70)
- Why are the features of BOTH A and B Required with the presence of EITHER C or D?
- CAM is used to identify the presence of delirium in a person and assess possible causes of it
5. Discuss the role of the nurse and interprofessional healthcare team relating to the use of
pharmacological and nonpharmacological treatments for acute and chronic inflammation.
Complete the following chart regarding the use of non-pharmacological treatments for
inflammation:
How
Heat
Cold
• Measure the temperature of
the water by using a bath
thermometer.
• Fill the bag two-thirds full.
• Expel the remaining air and
secure the top. With the air
removed, the bag can be
moulded to the body part.
• Dry the bag and hold it
upside down to test for
leakage.
• Wrap the bag in a towel or
cover and place it on the
body site.
• Remove after 30 minutes or
in accordance with agency
protocol.
Determine the patient’s ability to tolerate
the therapy.
• Identify conditions that might
contraindicate treatment
(e.g., bleeding, circulatory impairment).
• Explain the application to the patient.
• Assess the skin area to which the heat or
cold will be applied.
• Ask the patient to report any discomfort.
• Return to the patient 15 minutes after
starting the heat or cold, and observe the
local skin area for any untoward signs
(e.g., redness). Stop the application if any
problems occur.
• Remove the equipment at the designated
time, and dispose of it appropriately.
• Examine the area to which the heat or
cold was applied, and record the
patient’s response.
What
hot water bag
hot packs
electrical pads
compress
ice bags
ice gloves
ice collars
compress
When
muscle spasm, contracture, join stiffness, traumatic injury, inflammation,
pain
Why (relate
to
inflamm
ation)
increase blood flow, softens
exudates
vasoconstriction decrease capillary
permeability decrease blood flow, slow
cellular metabolism
Slows bacterial growth,
decreases inflammation
(what other member(s) of the interprofessional health care team could use these treatments in the care
of their client?)
Application of heat and cold: kozier, p.961
6. Discuss current issues, trends and research related to infection. (Is there any current news
item that is relevant to use as an example?
7. Discuss the lived experience of a client and/or family experiencing an infection or
inflammation. Think about holistic implications 8. Explore the nursing implications for the administration of anti-inflammatory medications and
antipyretics:
Nonsteroidal anti- - Do not give drugs containing ASA to children; Reye’s syndrome is a lifeinflammatory drugs threatening disorder.
(NSAIDs):
- Take NSAIDs with food or milk to decrease gastric upset.
- Avoid alcohol
Analgesic, Antipyretic,
- antiConsult a healthcare provider before taking herbal products while taking
inflammatory
NSAIDs
Optimal effects from NSAID therapy may not occur for 1 to 3 weeks.
Ibuprofen
- Report immediately signs of bleeding such as
Acetylsalicylic acid - Pt who should avoid taking this med: pt who takes med for peptic ulcer
disease, takes vitamin K for a clothing disorder, and who performs peritoneal
(aspirin)
self-dialysis
- Dark-coloure durine or stool, increased bruising, or gingival bleeding;
unexplained fatigue; headache or dizziness; changes in hearing
(especially ringing in the ears); swelling; itching; or skin rash
- Acetaminophen: hepatotoxicity and 4g is max daily dose
- Reduce fever
- No effect on inflammation
-
Glucocorticoidsprednisone
Ibuprofen: Gastric irritation, nausea, vomiting
Aspirin: blood-clot, before surgery, wound care
Should not be given to pt who take heparin, warfarin or vitamin K
-
Take the medication at the same time each day.
Never abruptly discontinue taking the medication
Take with food to avoid gastric irritation.
Anti-inflammatory
Guard against infection: avoid persons with infections and wash hands
frequently.
Acute or severe inflammation
- Weigh yourself daily and check ankles and legs for signs of swelling, because
reserved for the short-term treatment of
corticosteroids are known to cause fluid retention. Edema because of water
severe disease
retention
side effects: suppression of the normal
- Immediately report the following: difficulty breathing; heartburn; chest,
functions of the adrenal gland (adrenal
abdominal, or joint/bone pain; nosebleed; bloody cough, vomit, urine, or stools;
insufficiency), hyperglycemia, mood
changes, cataracts, peptic ulcers, fever; chills; red streaks from wounds or any other sign of infection; increased
electrolyte imbalances, and
thirst or urination; fruity breath odour (or significantly elevated daily serum
osteoporosis.
glucose); falls or other accidents (deep lacerations may require antibiotic
Women who are receiving high-dose
therapy); and mood swings.
glucocorticoid therapy should be
warned against breastfeeding.
- Hyperglycemia and hypertension , be cautious about diabetic pt
- Stimulate appetite, chance to gain weight
- Effect of using for long time→ Cushing syndrome
9. Explore the nursing implications for the administration of antimicrobial/anti-infective agents
(as per course outline).
Focus your learning on the “Nursing considerations” and “Nursing Process Focus” for this content in
Adams. Make sure you review the “Prototype drug” for each classification.
*****You will be tested on content related to what the nurse needs to know for administration(e.g.
assessment prior to giving) and evaluation(e.g. therapeutic and side effects to watch for) and
teaching the patient about the drugs. Identify what is unique about each antimicrobial, not what
makes them the same.
Write 2 unique points about each of these antibiotics that you would want to assess or highlight
to your patient when teaching. Know the nursing implication , know lemore 28
How to remember: TFS (photosensitivity) , AM (ototoxicity)
Aminoglycosides
“Micins”
Gentamicin
Ototoxicity→ assess
MOC: Inhibit bacterial ADVERSE EFFECT:
hearing, dizziness
protein synthesis
more toxic than
(vertigo), ringing in the
other
ear (titintis) so it cannot USE: treatment of
antibacterial
Teaching clients
be ordered with other
serious systemic
classes, with
Increase fluid intake.
drugs with same side
infections caused by
serious systemic
Immediately report
effects, like furosemide
aerobic gramadverse effects;
significant side
negative bacteria,
nephrotoxicity;
effects, including
Nephrotoxicity→damage to
myobacteria, and
ototoxicity;
tinnitus, high
the kidney- Assess for
some protozoans
neurotoxicity
frequency
sudden weight gain,
hearing loss, persistent
urine output, edema,
headache, nausea,
BUN and creatinine
and vertigo, weight
gain of 5kg in 2
days
Cephalosporins
Assess for secondary
USE: for serious
“cefs” or “cephs”
infections(thrush, yeast
infections of lower
Cefazolin
infection). (Consuming
respiratory tract,
Teaching client
yogurt may prevent.)
central nervous
Take the medication on
system,
an empty stomach, Oral contraceptives→ use
genitourinary
1 hour before or
back- up birth control
system, bones,
2 hours after meals.
method
blood, and joints
Complete the
prescription
Increase consumption
of buttermilk or
yogurt to prevent
intestinal
superinfection.
Avoid use with alcohol→
may cause severe
hypotension, blurred
vision, weakness
adverse effect: also,
safe drugs,
adverse effects
similar to
penicillins
(crosssensitivity)
Tetracycline
Macrolides
“erythromycins
Avoid excessive sun
use: drug of choice for
exposure to reduce the
Rocky Mountain
risk of photosensitivity
spotted fever,
reactions.
typhus, cholera,
Lyme disease,
Decrease absorption when
peptic ulcers, and
taken with calcium or
Chlamydia; newer
iron
ones for drugMOC: effective against broad
resistant intrarange of gram-positive
abdominal
and gram-negative
infections and
organisms
complicated skinstructure
infections,
especially those
caused by MRSA
Adverse effects:
superinfections,
nausea,
vomiting,
diarrhea,
discoloration of
teeth,
photosensitivity;
drug resistance a
major concern
Give with a full glass of
USE: for whooping
ADVERSE EFFECT:
water. Do not
cough;
nausea,
administer with acidic
Legionnaire's
abdominal
Gastric distress is a
fruit juice.
disease; infections
cramping and
common side effect May inhibit metabolism of
by streptococcus, H.
vomiting,
with erythromycin.
several drugs (check
influenzae, and
diarrhea,
individual drug lists)
Mycoplasma
superinfections,
GI irritation is common
pneumoniae
concern about
Take medication on an
(especially with
resistant
empty stomach
erythromycin)
bacterial strains,
Avoid acidic food
ototoxicity
Superinfections
MOC: Inhibits protein
synthesis by binding to
ototoxicity and
the bacterial ribosome
know
- Effective against most
signs/symptoms
gram-positive and many
of this to inform
gram-negative bacteria
patient what to
watch for
Penicillins
“cillins”
Penicillin G
Antacids may ↓absorption USE: meningitis; skin,
ADVERSE EFFECT:
of penicillin
bone and joint
the safest class
Assess for secondary
infections; stomach
of antibiotics;
infections(thrush, yeast
infections; blood
bacteria can
Notify the physician if
infection). Consuming
and valve
become
you see white
yogurt may prevent.
infections; gas
resistant; allergy
patches on the oral
gangrene; tetanus;
is possible;
mucosa or if vaginitis
Client teaching: Consuming
anthrax; sickle-cell
lowered
develops. An
yogurt or buttermilk
anemia in infants
red/white blood
antifungal drug may
may prevent
cell and platelet
be
superinfection. Do
levels
prescribed and the
not take these products
antibiotic
within 1 hour of taking
Superinfection
continued.
the drug.
Allergy- rash
Fluoroquinolones
“floxacins”
Teach client:
- Wear sunglasses; avoid
exposure to bright
lights and direct
sunlight
when taking norfloxacin.
- Report the first signs of
tendon pain or
inflammation.
- Report the following
side effects
immediately:
dizziness,
restlessness,
stomach distress,
diarrhea, psychosis,
confusion, and
irregular or fast heart
rate.
Photosensitivity→avoid
USE: for respiratory ADVERSE EFFECT:
exposure to sunlight
infections, GI and
nausea,vomiting,
Rash should be reported
genitourinary tract
diarrhea, sleep
immediately
(r/t
infections, and some
disturbances,
photosensitivity)
skin and soft tissue
headache,
Restrict caffeine to avoid
infections,
dizziness. Most
excess
nervousness,
uncomplicated
serious:
anxiety, tachycardia
UTIs; prophylaxis of
dysrhythmias,
anthrax infection
hepatotoxicity
MOC: to inhibit bacterial
→ light, gracy
DNA synthesis by
stool
and
inhibiting DNA gyrase
jaundice, pain
and topoisomerase IV
Tendonitis
specially with
Store it dark bottle and dark
adolescents
place because it changes
male
SULFAMIDE
Teaching client:
MOC: Suppress bacterial Adverse
effects:
formulation of
crystals in the
urine,
hypersensitivity
reactions,
nausea,
vomiting.
Serious adverse
effects:
agranulocytosis,
acute hemolytic
anemia,
and
aplastic anemia
- Avoid exposure to direct
growth by inhibiting
sunlight; use sunscreen
bacterial synthesis
and protective
of folic acid
clothing to decrease effects of
photosensitivity.
USE: for urinary tract
- Take oral medications with a
infections,
full glass of water.
Pneumocystis
- Increase fluid intake to 1500
carinii pneumonia,
to 3000 mL per day unless
shigella infections of
otherwise
small bowel
contraindicated.
- Immediately report
significant side effects,
including abdominal
or stomach cramps or pain,
Nursing intervention and rationales (Adam, p.537)
- Monitor vital signs and symptoms of infection to determine antibacterialeffectiveness. (Another
drug or different dosage may be required.)
- Monitor for hypersensitivity reaction. (Immediate hypersensitivity reaction may occur within 2 to
30 minutes; accelerated occurs in 1 to 72 hours and delayed occurs after 72 hours.)
Monitor for severe diarrhea. (The condition may occur due to superinfection or the possible
adverse effect of AAPMC.)
- Administer drug around the clock (to maintain effective blood levels)
Monitor for superinfection, especially in elderly, debilitated, or immunosuppressed clients.
(Increased risk for superinfections is due to elimination of normal flora.
Monitor intake of OTC products such as antacids, calcium supplements, iron products, and laxatives
containing magnesium. (These products interfere with absorption of many antibiotics.)
- Monitor for photosensitivity. (Tetracyclines, fluoroquinolones, and sulfonamides can increase
client’s sensitivity to ultraviolet light and increase risk for sunburn.
- Determine the interactions of the prescribed antibiotics with various foods and beverages.
- Monitor IV site for signs and symptoms of tissue irritation, severe pain, and extravasation.
- Monitor for side effects specific to various antibiotic therapies.
- Monitor renal function such as intake and output ratios and urine colour and consistency. Monitor
lab work including serum creatinine and BUN. (Some antibiotics such as the aminoglycosides are
nephrotoxic.)
- Monitor for symptoms of ototoxicity. (Some antibiotics, such as the aminoglycosides and
vancomycin, may cause vestibular or auditory nerve damage.)
- Monitor client for compliance with antibiotic therapy.
11. Complete Mr. Fields Case study on e.centennial prior to class.
· Select priority need
· Include data + gap in data
· Analysis (with reference)
·
·
·
·
One Nursing Diagnosis
Two expected outcomes
Two Evaluative Methods
4 nursing interventions with rationale
Week 6- READ LEMORE CHAPTER 10
STUDY GUIDE
The role of the nurse in the care of a client with a fluid and/or electrolyte imbalance and
implications for nursing practice.
*Independent Study: Complete a data analysis on Case Study 44 on Kozier et al. 3rd edition
2014, p. 1469 or 4th ed. P. 1387 – you can refer to mynursinglab for help if you want with
some answers (focus on fluids and sodium/potassium imbalance – NOT Acid-base
implications!)- learning circle
1. Outline the factors influencing fluid and electrolyte balances (specifically sodium and
potassium). Kozier, p. 1335
Homeostasis relies on the balance of fluids, electrolytes, acids & bases.
There are many Factors that put the balance at risk – Describe with examples
- Age- older adult in risk of dehydration because the thirst mechanism declines
- Sex and body size- 60% of an adult male’s wight and 52%of an adult female’s weight
- Environmental temperature
- Lifestyle
2. Describe relevant subjective and objective assessment findings associated with fluid and
electrolyte imbalances. (added to the table)
3. Identify therapeutic measures to correct fluid, sodium and potassium imbalances.
Think about your experiences when you have….
- been sick with gastroenteritis
- been exercising or heavily sweating
- eaten a whole bag of potato chips!
Now look at your readings – What therapeutic measures are there that you forgot to include above?
What therapeutic measures are there that are new and you had not considered before?
Intake 2400-2800ml
o Oral fluids
o Tube feedings
o Parenteral fluids(IV’s and IV meds):
§ IV fluids may be used when patient unable to take by mouth or hydration needs to be rapid
§ IV fluids and IV therapy will be in Semester 3 content (focus your attention to other means of
hydration this semester)
o Blood products
Output 2200-2600ml
o Urine
o Feces
o Vomitus
o Tube drainage
o Wound drainage
o Consider – diaphoresis, rapid deep respirations, perspiration
4. Discuss the nursing role in teaching clients to maintain and/or correct fluid and electrolyte
imbalances. (look at table for implementation)
Review dietary considerations. What foods contain sodium? What foods contain potassium? What have
you eaten today ...do you know how much of each electrolyte you have consumed? Where do you
find this information?
5. Using a case study, apply the nursing process to develop a care plan including
establishing priorities in nursing care to promote fluid and electrolyte balance.
Describe relevant subjective and objective assessment findings associated with fluid and electrolyte
imbalances.
assessment
(a) the nursing history
(b) physical assessment of the client
(c) clinical measurements
Daily wight
Vital signs
Input and output
(d) review of laboratory test results
Lab
1. CBC - specifically hematocrit – (Relating to
Assessing fluid volume deficit :
Subjective:
Thirst
Weakness
Weight Loss
objective:
< BP, > P, < T
< weight
BP lying, sitting & standing (a BP drop 10 – 15 mm
Hg > P by 10 bpm = orthostatic or postural
hypotension)
mental status altered
fluid balance, what is significance of low
HCT? High HCT?)
2.Electrolytes – specifically sodium, potassium,
creatinine, blood urea nitrogen (BUN)
3.Serum albumin
4. Serum osmolality
5.Urine – pH 4.5 to 8
specific gravity
Osmolality
Normal specific gravity ranges from 1.010 to 1.025
Sodium 135-145 mmol/L
Potassium 125-140 mmol/L
Normal Hct values- important to check for
dehydration
0.37 to 0.49 (males) and 0.36 to 0.46 (females)
HIGH → dehydrated Low→ excess
Normal BUN
HIGH→ dehydration
Diagnosis
Fluid volume deficit
Fluid volume excess / overload
Risk for fluid imbalance (deficit or excess)
Impaired Fluid volume excess / overload
Risk for fluid imbalance (deficit or excess)
gas exchange
Impaired skin integrity (or risk for…)
Activity Intolerance
Risk for impaired gas exchange
Decreased Cardiac output
Risk for injury
Mucous membranes dry
< Jugular veins
Skin turgor – over sternum or forearm. If tents =
poor
Lab Values
HCT, Serum osmolality
Urine specific gravity
Assessing fluid volume excess:
subjective:
Cough, SOB
Difficulty sleeping lying down
Recent weight gain
Risk factors (CHF, renal cirrhosis, endocrine
corticosteroids, NSAIDS)
objective
> VS
> weight
Mental status changes
Peripheral or facial edema
Moist Mucous membranes, skin
Distended jugular
Chest – crackles, wheezes
Fluid volume deficit
causes
GI fluid loss
> urine output(diuretics, diabetes)
Hemorrhage- blood loss
Sweating
Fever
Draining Wounds
Fluid Shifts (third spacing)
Inadequate fluid intake
Manifestations
Fatigue
Altered mental status
Postural hypotension
Tachycardia, weak thready pulse
Weight loss
Flat neck veins, < CVP
Poor skin turgor, dry skin
Decreased urine output
Concentrated urine
decrease blood pressure
increase hematocrit (hct)
SIGNS of dehydration in older adults
Thirsty
< Urine output <30ml/h
Dark-colored urine, and other body fluids
Dry skin, < skin turgor
Feeling tired or dizzy
Fainting
Below normal temp
Etiology
Increased losses through the skin,
gastrointestinal tract, or kidney
Decreased intake of fluid
Bleeding
Movement of fluid into a third space
Fluid volume excess
causes:
CHF
Renal- kidney condition
Medications- ex glucocorticoid
Excess fluid intake
Excess sodium intake
Cirrhosis of the liver, kidney and heart failure
Manifestation
> BP, P, R
Moist crackles, wheezes
Weight gain
Distended neck veins
Dependent edema
< HCT, < urine specific gravity, < serum osmolality
Etiology
Excessive intake of sodium chloride
Administration of sodium-containing infusions
too rapidly
Disease processes that alter regulatory
mechanisms, such as heart
failure, renal failure, cirrhosis of the liver, and
Cushing’s syndrome
planning
Promoting healthy fluid and electrolyte balance
Lab values (Na, K, Hc, BUN)
Treatment of fluid volume deficit
Kozier, p. 1353
-Consume 2000 to 2500 mL water daily, unless
contraindicated.
-Avoid excess amounts of foods or fluids high in
salt, sugar, and caffeine.
-Eat a well-balanced diet according to Eating Well
with Canada’s Food Guide
- Limit alcohol intake because it has a diuretic
effect.
-Increase fluid intake before, during, and after
strenuous exercise, particularly when the
environmental
temperature is high, and replace lost electrolytes
from excessive perspiration as needed with
commercial electrolyte solutions.
- Maintain a normal body weight and body mass
index for age and sex.
- Learn about and monitor side effects of
medications that affect fluid and electrolyte
balance (e.g., diuretics)
and ways to handle side effects.
- Recognize possible risk factors for fluid and
electrolyte imbalance, such as prolonged or
repeated vomiting,
frequent watery stools, or inability to consume
fluids because of illness.
- Seek prompt professional health care for notable
signs of fluid imbalance, such as sudden weight
gain
or loss, decreased urine volume, swollen ankles,
shortness of breath, dizziness, or confusion
Client goals and expected outcome- Adam, p.662
Client will….
• Exhibit normal fluid balance and maintain
electrolyte levels within normal limits during
drug therapy
• Demonstrate an understanding of the drug’s
action by accurately describing drug side
effects and precautions
• Immediately report effects such as symptoms of
hyperkalemia or hypokalemia and
-
> fluids, > electrolytes if low (Pedialyte, Gatorade),
IV fluids
Assess skin turgor
Adjust activity level and fluid intake in hot
weather
Vomiting – small frequent ice chips, or clear
liquids
(Coffee, Tea, alcohol, sugar, salt increases urine
output and can increase fluid loss – do not
provide)
***Monitor weight (same time (daily), scale,
clothes), VS
***lab values
Provide frequent mouth care so as to decrease
unpleasant taste in the mouth or stimulate thirst
Provide safety
Treatment of fluid volume excess
Monitor daily weight – report if >’d ( 2 kg weight
gain = app. 2 liters of fluid gain)
Monitor edema
***Fluid restrictions (ice chips, soups, jello,
pudding, custard, ice cream are all considered
fluids)
*** Oral hygiene – prevent thirst
Rest, feet elevated to promote reabsorption of
fluid
Semi fowlers for dyspnea, arms supported
Low sodium diets
No processed foods
Use herbs, spices, lemon juice, vinegar & wine for
seasoning
Use salt substitutes sparingly (may taste bitter
and may have > K+)
Read labels
Reduce dependant edema, position changes,
support hose
Kozier, p.1352
maintain or restore normal fluid balance
prevent associated risks (tissue breakdown,
decrease cardiac output, confusion, other
neurological signs)
hypersensitivity
Implementation
Read more on Kozier, p.1355
antidiarrheal Meds
Use sparingly – may mask underlying cause
which should be treated
Use for symptomatic relief while underlying
etiology is determined
If diarrhea persists for more than 2 days or
accompanied by fever, seek medical attention
If blood in stool, seek medical attention
Do not use if constipation should be avoided
(e.g. colitis
Nutrition notes for treatment diarrhea
Following the “BRAT” diet (banana, rice,
applesauce and toast)
Soft bland food
Bananas
Plain rice
Boiled potatoes
Toaste
Crackers
Cooked carrots
Baked chicken without the skin or fat
Children can eat bananas, rice, applesauce, and
toast (BRAT diet)
Fluid volume deficit
Assess for clinical manifestations of fluid volume
deficit (FVD).
Monitor weight and vital signs, including
temperature.
Assess capillary refill time.
Assess tissue turgor.
Assess breath sounds.
Monitor fluid I&O.
Monitor laboratory findings.
Provide frequent mouth care so as to decrease
unpleasant taste in the mouth and stimulate thirst
Administer oral and IV fluids, as indicated.
Implement measures to prevent skin breakdown.
Provide for safety, for example, provide
assistance to a client rising from bed.
Fluid intake- promoting
◦ Set small short term goals – e.g. 1 glass/hour while
awake
◦ Identify likes/dislikes – coffee/tea diuretics – do
count as intake but will not promote hydration, so
limit amount
◦ Appropriate drinking utensils within reach–
straw/cup
◦ Client maintain fluid record if possible
◦ Select foods that melt at room temp (solid→liquid)
Fluid volume excess
Assess for clinical manifestations of FVE.
Monitor weight and vital signs.
Assess for edema.
Assess breath sounds and dyspnea.
Monitor fluid I&O.
Monitor laboratory findings.
Place client in the Fowler’s position.
Administer diuretics, as ordered.
Restrict fluid intake, as ordered.
Restrict dietary sodium, as ordered.
Implement measures to prevent skin breakdown
Fluid intake- restricting
◦ Compliance can be difficult
◦ Explain rationale to patient AND visitors
(↑compliance)
◦ Develop a 24 hour plan for fluid restriction
•e.g. Give ½ total volume on day shift
•other ½ given on evenings (more) & nights (less)
Example) 1 L restriction = 500 mL day, 350 mL
evening, 150 nights
**Ice chips= ½ volume when melted
◦ Give fluids in small glasses
◦ Offer frequent mouth care
◦ Avoid salty, sweet, hard candy, gum = ↑thirst
Electrolytes
Assessment
Assessing Fluid & Electrolyte Imbalances
Common risk factors for fluid and electrolyte
imbalances include chronic diseases, acute
conditions, medications, treatments, other
factors
Assessment interview, fluid & electrolyte and
Acid – Base balance
Note lifespan considerations
Physical assessment of electrolyte imbalances
Skin – color, temperature, moisture, turgor
Mucous membranes
Eyes
Fontanelles (infants)
HR, BP
Peripheral pulseS
Capillary refill
Respiration
Lung sounds
Neuro**** changes occur in elderly quickly
with fluid and electrolyte imbalances
LOC, Orientation, motor function, reflexes
(Kozier et al, P. 1391)
Diagnosis
Sodium – hyponatremia
Manifestation
HA, Mental status changes *most important
Anorexia, N/V
Abdominal cramping
**Muscle weakness
**Hyper reflexia muscle twitching
Causes
> NA loss (vomiting, diarrhea, gastric suctions)
Diuretics
Inappropriate secretion of Antidiuretic hormone
Potassium- hypokalemia
Manifestation
**Dysrhythmias (both hypo and hyper)
N/V
Anorexia, nausea , vomiting
Decreased bowel sound
**Muscle weakness or leg cramps
Fatigue and lethargy
Causes
Vomiting
Diarrhea
Ileostomy drainage
Diuretics, corticosteroids, NPO
Planning
Treatment for hyponatremia
Replace sodium (cup noodles, Gatorade, IV)
Check lab values
Restrict water intake
Treatment for hypokalemia
Food (banana, carrots, tomato, fish, avocado,
date, cauliflower)
Potassium can also be replaced through
medications (e.g. Micro-K, K-dur, KCl elixir
Teach client how to prevent excessive loss of K
(ex. Through avoiding abuse of diuretics and
laxatives)
Take apical pulse
Implementation
Hyponatremia
Assess clinical manifestations.
Monitor fluid I&O.
Monitor laboratory data(e.g., serum Na+).
Assess client closely if administering
hypertonic saline solutions.
Encourage food and fluid high in Na+, if
permitted (e.g., processed foods, table salt).
Limit water intake, as indicated.
6. Explore the nursing implications for the administration of the diuretics. Adam, p. 661
Nurse will…
- • Monitor laboratory values. (Diuretics can cause electrolyte imbalances.)
- • Monitor vital signs, especially blood pressure. (Diuretics reduce blood volume, resulting in
lowered blood pressure.)
- • Observe for changes in level of consciousness (LOC), dizziness, fatigue,and postural hypotension.
(Reduction in blood volume due to diuretic therapy may produce changes in LOC or syncope.)
- • Monitor for fluid overload by measuring intake, output, and daily weight. (Intake, output, and
daily body weight are indications of the effectiveness of diuretic therapy.)
- • Monitor potassium intake. (Potassium is vital to maintaining proper electrolyte balance and can
become depleted with thiazide or loop diuretics.)
- • Observe for signs of hypersensitivity reaction.
- • Monitor hearing and vision. (Loop diuretics are ototoxic. Thiazide diuretics increase serum
digitalis levels; elevated levels produce visual
- changes.)
- • Monitor reactivity to light exposure. (Some diuretics cause photosensitivity.)
Client education
- • Instruct client to inform laboratory personnel of diuretic therapy when providing blood or urine
sample
Instruct client to:
- • Monitor blood pressure as specified by the healthcare provider, and ensure
- proper use of home equipment
- • Withhold medication for severe hypotensive readings as specified by the healthcare provider (e.g.,
“hold for levels below 88/50”)
Instruct client to:
- • Immediately report any change in LOC, especially feeling faint
- • Avoid abrupt changes in posture; rise slowly from prolonged periods of sitting or lying down
- • Obtain blood pressure readings in sitting, standing, and supine positions
Instruct client to:
- • Immediately report any severe shortness of breath, frothy sputum, profound fatigue and edema in
extremities, potential signs of heart failure, or pulmonary edema
- • Accurately measure intake, output, and body weight and report weight gain of 1 kg or more within
2 days or a decrease in output
- • Avoid excessive heat, which contributes to fluid loss through perspiration
- • Consume adequate amounts of plain water
For clients receiving loop or thiazide diuretics, encourage foods high in potassium
For clients receiving potassium-sparing diuretics:
- • Instruct client to avoid foods high in potassium
- • Consult with healthcare provider before using vitamin/mineral supplements or electrolytefortified sports drinks
Instruct client or caregiver to report:
- • Difficulty breathing, throat tightness, hives or rash, and bleeding
- • Flu-like symptoms: shortness of breath, fever, sore throat, malaise, joint
- pain, profound fatigue
- • Instruct client to report any changes in hearing or vision such as ringing or
- buzzing in the ears, becoming “hard of hearing,” experiencing dimness of
- sight, seeing halos, or having “yellow vision”
Instruct client to:
- • Limit exposure to the sun or wear sunscreen
-
• Wear dark glasses and light-coloured, loose-fitting clothes when outdoors
What are the 3 main sources of fluid intake? Water we drink, water in food, water form by
catabolism
What is the normal total daily fluid intake? 2400-2800 mL
List four ways water is lost from the body. Urine, sweat, feces, insensible losses (lungs and skin)
What is the normal loss of fluid daily? 2200-2600 mL
Which organ is most important for regulating fluid balance? Kidney
List the signs & symptoms of fluid deficit and excess.
7. The signs of dehydration in babies and young children
- Dry mouth and tongue
- Crying without tears
- No wet diapers for 3 hours or more
- High fever
- Unusually sleepy or drowsy
- < skin turgor - It does not flatten back to normal when pinched and released.
8. Consideration of fluid imbalances in older adult (CHANGE IN MENTAL STATUS MAY BE THE
FIRST SIGN)
Older adults have (associated with aging)
- Decreased thirst sensation
- Decreased urine volume
- Decreased overall body water volume
- Decreased response for body to respond to dehydration
- May have increased use of diuretics, laxatives, chronic illnesses, infection (without obvious signs)
- May have decreased intake (food and liquids)
- Changes can happen quickly and become serious in short time →be alert!
Powerpoint
9. fluid intake restriction
Compliance can be difficult
Explain rationale to patient AND visitors (↑compliance)
Develop a 24 hour plan for fluid restriction
e.g. Give ½ total volume on day shift and other ½ given on evenings (more) & nights (less)
Example) 1 L restriction = 500 mL day, 350 mL evening, 150 nights
**Ice chips= ½ volume when melted
Give fluids in small glasses
Offer frequent mouth care
Avoid salty, sweet, hard candy, gum = ↑thirst
10. fluid intake promoting
Set small short-term goals – e.g. 1 glass/hour while awake
Identify likes/dislikes – coffee/tea diuretics – do count as intake but will not promote hydration, so
limit amount
Appropriate drinking utensils within reach– straw/cup
Client maintain fluid record if possible
Select foods that melt at room temp (solid→liquid)- gelatin, custard, sharbat if allowed
Week 6- diuretic therapy and drug for renal failure
1. Pharmacology
Attempts to manage cause of dysfunction
- Diuretics to increase urine output
- Cardiovascular drugs to treat hypertension or heart failure
- Dietary management
Restriction of protein, reduction of sodium, potassium, phosphorus, magnesium
2. Diuretics
- Increase rate of urine flow
- Excretion of excess fluid used to treat
- Hypertension, heart failure, kidney failure
- Liver failure or cirrhosis, pulmonary edema
3. Adverse effect of diuretic therapy
-
Fluid and electrolyte disturbances
Dehydration
Orthostatic hypotension
Potassium and sodium imbalances
4. Role of nurses
-
Pharmacologic Management of renal failure and diuretic therapy
Careful monitoring of patient's condition
Providing education relating to prescribed drug management
Obtainmedical, drug, dietary, and lifestyle history
Assess patient's weight, intake/output, skin turgor/moisture, vital signs, breath sounds, and
presence of edema
Loop diuretics- furosemide (lasix)
Loop or high-ceiling are most
effective diuretics
Mechanism of action: to block
reabsorption of sodium and
chloride in loop of Henle
Primary use: to reduce edema
associated with heart, hepatic
cirrhosis, or renal failure
Furosemide and torsemide also
approved for hypertension
Side effect: hyponatremia,
dehydration, hypokalemia
Teaching:
- Obtain baseline and monitor periodically lab values,
weight, current level of urine output
- Monitor electrolytes, especially potassium, sodium, and
chloride
- Monitor blood urea nitrogen (BUN), serum creatinine,
uric acid, and blood-glucose levels
- Assess for circulatory collapse, dysrhythmias, hearing
loss, renal failure, and anemia
- Monitor for side effects—orthostatic hypotension,
hypokalemia, hyponatremia, polyuria
- Observe for rash or pruritus
- Teach patients to take diuretics in the morning, change
position slowly, monitor weight
- Patients should take potassium supplements, if ordered,
and consume potassium-rich food
Thiazide diuretics
Largest, most commonly prescribed
class of diuretics
Hydrochlorothiazide
Mechanism of action: to block Na+
reabsorption and increase
potassium and water excretion
Primary use: to treat mild to
moderate hypertension
- Also indicated to reduce edema
associated with heart, hepatic,
and renal failure
Less effective than loop diuretics
Not effective in patients with severe
renal failure
Teaching patient:
- Hypokalemia is a problem for people taking Digoxin
- Obtain baseline and monitor periodically lab values,
weight, current level of urine output
- Measure electrolytes, especially potassium, sodium, and
chloride, prior to loop-diuretic therapy
- Monitor blood urea nitrogen (BUN), serum creatinine,
uric acid, blood-glucose levels
- Increased potassium loss may occur when used with
digoxin; may reduce effectiveness of anticoagulants,
antidiabetic drugs
- Increased risk of lithium toxicity when taking thiazide
diuretics
- Allergies to sulfa-based medications can indicate
hypersensitivity
- Use with caution in pregnant or lactating women
Side effects: HYPONATREMIA,
- Teach patient to
DEHYDRATION, HYPOKALEMIA - Use sunscreen to decrease photosensitivity
- Take potassium supplements, if ordered
- Consume potassium-rich foods
- Report any tenderness or pain in join
potassium -sparing diuretics
•Advantage: patient will not
experience hypokalemia
•Critical to assess electrolytes
-
Patients Taking lithium or digoxin may be at increased
risk for toxicity
Spironolactone contraindicated for pregnant or lactating
women
(potassium and sodium), blood
urea nitrogen (BUN), serum
creatinine
•Adverse effects: hyperkalemia,
and GI disturbances, muscle
weakness, impotence,
amenorrhea, gynecomastia
- also used as adjunctive therapy
in the treatment of hypertension
and congestive heart failure.
-
Report signs and symptoms of hyperkalemia
Spironolactone (Aldactone) may decrease effectiveness
of anticoagulants
Avoid use of potassium-based salt substitutes
When in direct sunlight, use sunscreen
Avoid performing tasks that require mental alertness
Do not eat excess amount of foods high in potassium
Do not use salt substitute if you are taking a potassium
sparing diuretic.
Take apical pulse
5. Drug therapy for renal failure
- Experiences a decrease in blood pressure
- Is free from, or experiences minimal adverse effects
- Verbalizes an understanding of the drug's use, adverse effects, and required precautions
- Demonstrates proper self-administration of the medication (e.g., dose, timing, when to notify
provider)
Week 7 case study kozier p.704
Kozier chapter 30 (P. 692, 693, 701, , Lemone chapter 9(P.164- END) , Murray 173-184 (CHAPTER 5
P.117, 114)
Pain is
-
One of the most common problems we face as health care providers
One of the most significant fears that people express
A fundamental human rights
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
Whatever the person says it is and exists whenever the person says it does
1.Identify the factors that influence the pain experience. (Kozier, p.676)
Factors that affect the pain experience – be able to give an example:
Ethnic and cultural values
Age / developmental stage
Previous experience with pain
Emotional status
Environment & support person
Meaning of pain
Anxiety & Stress
2.Discuss the key strategies, barriers and principles of pain management.
What do you do to relieve pain? What are the myths and facts of pain relief?
Barriers (kozier, p.960)
Strategies: kozier, p. 690
- Acknowledging and accepting
1. Verbally acknowledge the presence of the pain, and use standardized measures to clarify pain
intensity, quality, and impact.
2. Listen attentively to what the client says about the pain, restating your understanding of the
reported pain. Use empathetic statements, such as “I’m sorry you are hurting. It must be upsetting. I
want to help you feel better.”
3. Convey that you need to understand the client’s pain experience and whether pain treatments are
effective or not. Ask, for example, “Has the pain treatment reduced the intensity of your pain?”
4. Attend to the client’s needs for pain relief promptly. It is unconscionable to believe the client’s
report of pain and than do nothing!
*For clients experiencing acute or severe pain, the nurse may focus only on location, quality, severity, &
early intervention.
*The frequency of pain assessment depends on the intervention being used (e.g. a client receiving IV of
2.5mg of morphine, the severity of pain should be reassessed at the peak effect, which is 10-15 min)
- Assisting caregivers
- Reducing misbeliefs pain
- -Reducing a client’s misbeliefs about pain & its treatment will help to prevent inadequate pain
management.
- -Comprehensive discussions between a nurse and client about their pain experience, intensity,
quality, the impact of pain, its aggravating & alleviating factors, and any fears & concerns the client
may be struggling with (e.g. opioid addiction and adverse effects such as constipation).
- -Clients who refuse analgesics in fear of addiction, explaining that the pain is more tolerable as long
as he/she remains totally still underestimates the risks associated with immobility (e.g. muscle
atrophy, pressure ulcers).
- Reduce fear and anxiety
- -When clients have no opportunity to talk about the pain and associated fears, their perceptions
and reactions to the pain can intensify.
- -By providing accurate explanations, the nurse can also reduce many of the client's fears, such as a
fear of addiction or a fear that the will will always be present.
-
Preventing pain
-A preventative approach to pain relief involves the provision of measures to treat the pain before it
occurs or before it becomes moderate to severe.
- -Preemptive analgesia is the administration of analgesics before an activity or an invasive or
operative procedure to treat pain before it occurs.
- -Treating clients with a parenteral administration of an opioid can reduce postoperative pain and
decrease the potential for the development of chronic pain.
- *Barriers to pain management includes the attitudes of the nurse or client as well as knowledge
deficits. Clients respond to pain based on their cultural, personal experiences, and the meaning of
the pain has for them. For many people pain is expected and accepted as a normal aspect of illness
and treatments, such as surgery.
- *Clients may not report pain because they expect that nothing can be done, they think it is not
severe enough, they do not want to take medication, or feel it would distract or prejudice the health
care provided.
Pain control
-Teach the use of selected nonpharmacological techniques, such as relaxation, guided imagery,
distraction, music therapy, massages.
-Discuss the actions, potential side effects, dosages, frequency & route administration of prescribed
analgesics.
-Suggest ways to handle adverse effects of medications & describe warning signs of medication
overdose.
-Provide accurate information about tolerance, physical dependence, & addiction if opioid
analgesics are prescribed & these topics are of concern.
-Instruct client to use pain control measures before the pain becomes moderate to severe.
-Inform the client of the consequences of untreated pain.
3.Outline subjective and objective data collection in completing a comprehensive pain
assessment.
Why do we assess pain?
-
To understand the client’sexperience
To determine the cause of the pain
To manage the pain
From this assessment data, we plan client-centred outcomes and evaluate the efficacy of the treatment
This means that we base the plan on the client’s goals and determine effectiveness by comparing to the
client’s expectations.
Subjective data is critical!
When self-report cannot be obtained (e.g., infants, preverbal children, and children or older adults with
cognitive impairment, and critically ill clients), behavioural observation should be the primary
source for pain assessment (RNAO, 2013).
Assessment
Kozier, p.679
For example, following the
must be initiated by the nurse
often considered the fifth vital sign
frequency of assessment depends on client situation
Subjective
intravenous
Refer to Health Assessment: “PQRAST” (depending on what tool you are most
administration of 2.5 mg of morphine,
comfortable using) = What questions will you ask the client?
the severity of
Precipitating/Palliating (aggravating/alleviating) factors: How did your pain
pain should be reassessed at●the peak
effect, which is
What were you doing when the pain appeared? What makes the pain worse?
within 10 to 15 minutes.
start?
What
makes the pain better? What have you tried to alleviate your pain, and has it helped?
● Quality/Quantity: In your own words, describe what the pain feels like. Some of the
The goal of
descriptors the client may use are burning, aching, dull, sharp, gnawing, shooting, or
pain assessment is to get a
stabbing. On a scale from 0 to 10 (with 0 meaning “No pain” and 10 meaning “Worst
comprehensive description of
this subjective experience.
possible pain”), how would you rate the level of pain you are having?
● Region/Radiation: Where do you feel the pain? (point/describe). Does the pain
radiate to any other regions of your body?
PQRASTU
● Signs, Symptoms: Do you have any swelling, redness,fever? Do you have any other
RATING
symptoms or sensations (e.g., nausea, dizziness, blurred vision, shortness of breath,
BODY MAP
anxiety, fatigue) in addition to your pain?
● Timing: When did or does the pain start? How long have you had it, or how long
does it usually last? How long are the pain-free periods, if there are any? What is the
frequency of the pain attacks?
● Understanding: How do you interpret your pain? Have you felt a similar kind of pain
before, and if so, can you describe the situation? What outcomes (implications) do
you anticipate from this pain? What do you fear most about your pain? How does
the pain make you feel (e.g., anxious, depressed, frightened, tired)?
Client history: type of employment and roles in the family, Coping resources
Objective
- Physiological:
acute pain: muscle tension, tachycardia, rapid and shallow respiration, increase BP,
dilated pupils, sweating and pallor, Response to threat with anxiety and fear
- Chronic pain: Other autonomic nervous system responses such as nausea, vomiting,
pallor, or sweating ma not occur with persistent pain. The patient with chronic pain
often is depressed, may have difficulty sleeping, and may be preoccupied with
the pain.
Behavioural
Assessing people with cognitive impairment
-
Behaviour changes: (more confused, decreased appetite, withdrawn, decline in
functioning)
Resistance to care: (pushing, aggressive, arguing, refusing, yelling)
Non-verbal cues: (facial grimacing, tense body, pacing, rocking, wandering)
Diagnosis
Pain(indicate where, type) r/t (factors) s/b (symptoms)
This diagnosis will / may also lead to :
the nurse should specify theActivity
specific
intolerance
Anxiety
location (e.g., right
Body
image
disturbance
Coping difficulties
ankle pain, or left frontal headache)
Hopelessness
Sleep pattern disturbance
Social interaction changes
Sexual practices alteration
Thought process alteration
Knowledge deficit
planning
PLANNING methods
Kozier example, p.687
1. Pain control, as evidenced by demonstrating willingness and
ability to report pain to the health care team and use pharmacological and
nonpharmacological pain relief measures appropriately.
2. Pain level controlled as evidenced by no or mild reported pain; increased movement
and use of inspirometer, decreased nausea, protective body positioning; return to
baseline of blood pressure (BP),
heart rate (HR), respirations (R).
***Define “preemptive analgesia”. How will you follow this approach in your nursing
care? KOZIER P. 691
- The administration of analgesics before an invasive or operative procedure to treat
pain before it occurs. For example, evidence suggests that treating clients
preoperatively with local infiltration of an anesthetic or parenteral administration
of an opioid can reduce postoperative pain and decrease the potential for the
development of chronic pain
Examples from kozier and lemore
Modify or minimize pain to enable partial or complete resumption of daily activities.
Enhance abilities to control pain or to cope with pain.
- Demonstrate actions to control pain and associated symptoms.
- Return for follow-up visits with a journal of activities and pain experiences.
After 3 to 5 days on regularly scheduled doses of pain medication, report a decrease
in the level of pain from 7 to 3 or 4 on a scale of 1 to 10.
- Decrease number of absences from work.
- Modify activities at work and at home, especially when pain is intense.
Acute pain: Patient will demonstrate pain control through appropriate and established
pain assessment scale
Chronic pain: Patient will verbalize pain level at acceptable level using agency-specific
pain scale, demonstrate ability to maintain optimal level of functioning, and report
ability to maintain role
Performance and interpersonal relationships.
Implementation
- includes both pharmacology & non pharmacological
- know the how, what & when each one will be used
Goal: - high priority is to control & manage pain at a level that is acceptable to pt.
You must read lemore
- p.individualized approach should be used – (see BPG p. 37 and video Principles of
171- 174 for
Effective Pain ControlRC262.P28.vcass2)
intervention and
multidisciplinary approach is best
outcome
break down the barriers & reduce misconceptions
What do you think about the “Comfort Basket” as described in Murray p. 118? What
would be in your Comfort Basket?
- Warm blanket
- Music
- Video game
- Crossword puzzles
- Reading book
- Magazin
- Lotions
- Aromatherapy
- Mouth care supplies
- Make-up
- Prayers
Physical
-cutaneous stimulation
- massage
·
application of heat / cold– also refer to readings for PNUR125 r/t heat and cold
application
·
acupressure
·
contralateral stimulation
·
reflexology
- immobilization
·
splints
·
supportive devices
- transcutaneous electrical nerve stimulation
-acupuncture
Cognitive behaviours
- Distraction
- Relaxation respons
-Psychoeducation
Key strategies in pain management
● Recognize need for preemptive analgesia →treat pain beforeit starts
● Acknowledge and accept
● Assist caregivers, provide resources
● Reduce misbeliefs, fear, anxiety
● Be prepared to provide combination treatments
● Non-pharmacology methods work best when pain is already controlled
Pain management on kozier p.668 case study
Home Care kozier, p. 690
Understanding pain and monitoring it for changes are important
tasks when a client returns home:
- Teach the client to keep a pain diary to monitor pain onset, activity before pain, pain
intensity, aggravating and alleviating factors, use of analgesics or other pain relief
measures.
- Instruct the client to contact a health care professional if planned pain control
measures are ineffective or adverse effects arise and are problematic.
Pain Control
- Teach the use of selected nonpharmacological techniques, such as relaxation, guided
imagery, distraction, music therapy, massage, and so on.
-
Discuss the actions, potential adverse effects, dosages, frequency, and route of
administration of prescribed analgesics.
- Suggest ways to handle adverse effects of medications and describe warning signs of
medication overdose.
- Provide accurate information about tolerance, physical dependence, and addiction if
opioid analgesics are prescribed and these topics are of concern.
- Instruct the client to use pain control measures before the pain becomes moderate
to severe.
- Inform the client of the consequences of untreated pain.
- Demonstrate and have the client or caregiver redemonstrate appropriate skills to
administer analgesics (e.g., skin patches, injections, infusion pumps, or patientcontrolled analgesia [PCA]), when appropriate.
KEY STRATEGIES IN PAIN MANAGEMENT KOZIER, P. 690
1. Verbally acknowledge the presence of the pain, and use standardized measures to
clarify pain intensity, quality, and impact.
2. Listen attentively to what the client says about the pain, restating your
understanding of the reported pain. Use empathetic statements, such as “I’m sorry
you are hurting. It must be upsetting. I want to help you feel better.
3. Convey that you need to understand the client’s pain experience and whether pain
treatments are effective or not. Ask, for example, “Has the pain treatment reduced
the intensity of your pain?”
4. Attend to the client’s needs for pain relief promptly. It is unconscionable to believe
the client’s report of pain and then do nothing!
Example
- Encourage discussion of pain, and acknowledge belief in Ms. Akers’ report of pain.
- Consult with a physician for an appropriate nonsteroidal antiinflammatory
analgesic with a minimum of side effects, and instruct in maintaining regular dosing
schedules.
- For episodes of acute pain, take opioid analgesic as soon at the pain begins and
every 6 hours while continuing the dosage of NSAID analgesic.
- Teach one relaxation technique that is personally useful.
- Explore distraction techniques such as listening to music, watching comedies, or
reading.
- Provide clinic phone number and instruct to call if pain is unrelieved with opioid
and NSAID analgesics
Acute pain intervention: Lemon, p.171-173
Chronic pain intervention:
• Ask the patient to describe the pain and its meaning, including
its effects on lifestyle, self-concept, roles, and relationships. Pain
is a stressor that may affect the patient’s coping ability. Chronic pain
often interferes with sleep quality, job performance, personal relationships,
and social interactions. The patient may have concerns about
Addiction to pain medication and costs as well.
• Assess for depression using an accepted depression screening tool.
Chronic pain and depression commonly occur concurrently (Longo
et al., 2013).
• If the underlying cause of chronic pain has not been identified,
advocate for consultations, diagnostic testing, or other means
of establishing an accurate diagnosis. Guidelines for chronic pain
management call for treatment of the underlying cause whenever it
can be identified (WHO, 2008b).
• Administer prescribed NSAIDs, opioid and nonopioid analgesics,
and other medications around the clock and as ordered. Whenever
possible, the oral or transdermal routes should be used. Around-the clock
analgesic administration helps maintain pain within an acceptable
range within which the patient remains comfortable and functional.
As-needed medications may be required for breakthrough pain.
• Do not crush, break, or allow patients to chew controlled-release
oral preparations. Crushing, breaking, or chewing controlled-release
oral preparations may lead to overdose. Capsules containing controlled- release pellets
can be opened and sprinkled over soft food.
See the accompanying Nursing Care of the Older Adult box for more
information about standards of pain management in older adults.
• Teach the patient, family, and caregivers how to manage side
and adverse effects of prescribed medications. Advise about the
importance of taking NSAIDs with food to reduce the risk of
Gastrointestinal irritation and bleeding. Provide information
about appropriate laxatives for the patient taking opioid analgesics.
Instruct when to contact the prescribing care provider should adverse effects become
problematic. Many analgesics, while effective,
have adverse effects that may limit the patient’s willingness to
continue therapy. In most cases, appropriate management of these
effects allows continued use of the medication.
• Encourage and advocate for a multimodal approach to pain
management, teaching about the use of heat, cold, and CAM
Therapies ( including acupuncture, chiropractic and aosteopathic medicine, massage, and relaxation), providing for
referrals to healthcare providers (e.g., physical therapists, chiropractic physicians,
massage therapists, acupuncturists) and chronic pain clinics as appropriate. Using a
multimodal approach
to management of chronic pain improves the patient’s perception of control over the
pain and its effect on lifestyle. This also may result in less dependence on opioid and
nonopioid analgesics.
Evaluation
Need to continually evaluate and re-evaluate when you provide interventions for pain
management – Are the interventions effective? What changes need to be made?
Alternative options?
4. Identify symptom assessment tools and valid pain scales for verbal and nonverbal client
populations. Murray p. 77-79
- behavioural observation should be the primary source for pain assessment
Symptom Assessment Tool: use to assess a person’s symptoms, with the goal of determining its
causes and the person’s understanding and experiencing of the symptoms, as well as track changes
in response to treatment or resulting from disease progression
Rating scale:
-
Mild pain is rated as being from 1 to 3 on a 0-to-10 rating scale.
Moderate pain is rated as being from 4 to 6 on a 0-to-10 rating scale.
Severe pain is rated as being from 7 to 10 on a scale of 0 to 10.
Body map:
Valid pain scales for verbal and nonverbal
A)facial grimace and behaviour assessment tool: used to help identify, on the basis of a person’s
facial expression or behaviour when the person might be experiencing pain or distress
B)Pain assessment in advanced dementia (PAINAD): used to assess a person’s pain on the basis
of five parameters of observed behavior. The tool is used when people with dementia are no
longer able to verbally communicate their pain. Higher score indicate pain that lower score but it
does not indicate the severity of the pain.
- This should be administered
- At admission
- At each quarterly nursing review
- During every shift for people whose behaviours suggest their pain is not controlled
- Each time a change in a person’s pain status reported
- Following a pain intervention (within one hour) to evaluate treatment effectiveness
- breathing (normal, labored, hyperventilation), vocalization (moaning, calling out, crying), facial
expression (smiling or without expression, sad, frowning, grimacing), body language (relaxed,
tense, rigid or striking out), and consolability (distractible, reassured, or unable to console)
C) Non-communicative patient’s pain assessment instrument (NOPPAIN): murray p.77
used while providing care to assess pain on the basis of observing a person’s behaviour and facial
expression.using this tool daily to assess the person’s pain can help to prevent pain from escalating
facilitates early detection of new pain.
Ask patient to write down the pain 0/10
What about assessing people with cognitive impairment?
Note: Most common indicators of pain:
-
Behaviour changes: (more confused, decreased appetite, withdrawn, decline in functioning)
Resistance to care: (pushing, aggressive, arguing, refusing, yelling)
Non-verbal cues: (facial grimacing, tense body, pacing, rocking, wandering)
5. Define breakthrough pain, equianalgesic dosing, titration and co-analgesia/adjuvants.
Murray, p. 113, kozier, p.692 example
Can you explain these terms? Can you teach these terms and their implications to others?
Breakthrough pain can occur when the pain is not well controlled and can more accurately be called
“end of dose failure”
●
Acute, transient, intermittent recurrence of pain
●
●
●
Exacerbation of severe pain
May be related to activity, dressing changes, sudden movement or unknown etiology (like shower)
“Individuals with chronic pain should have an immediate release opioid for pain break through that occurs between administration times of the
‘round the clock’ medication schedule”
*BTP is not a result of inadequate, irregular dosing and is not a “new pain” → Occurs even if pain is well
controlled when receiving scheduled analgesics
•Uses same medication as the regular scheduled drug (if possible)
•Must be immediate release vs. long-acting
•Usually ½ the regular q4h dose or 10% of long-acting dose
•Administer by simplest route possible, but ensure it will be absorbed in a timely manner based on
findings of pain assessment (e.g. maybe subcutaneous vs. oral if pain is severe)
•If multiple BTP doses are required in a 24 hour period →Report to physician to reassess scheduled
dosage amount
Equianalgesic dosage- use Equianalgesic conversions when switching opioids. For example if the pt is
switching to a new opiod , it is important to give a equivalent dose of new opioids. Less powerfulthere is a table that gives the equianalgesic for each dosage of opioid
Titration - the process of increasing and sometimes decreasing the medication to meet the desired
effects. Titration is considered at the beginning of drug therapy and repeatedly during the course of
treatment
• Advocate for the least invasive pain management modality, individualized to the person
• Use the ‘step-wise’ approach for selection of analgesic
• Dosing should be initiated at lower dosages and increased slowly “start low and go slow”
Adjuvants/ ANTICONVULSANT medications that assist with pain management, and they usually have
a different primary purpose than treating pain. Not specifically for pain- example anti seizure and
antidepressant. Adjuvant drugs are used to manage fear and anxiety. Similar to antidepressant , use
for pain and sleep disruption..
6. Discuss the role of the nurse and interprofessional healthcare team relating to the use of
pharmacological and non-pharmacological methods in pain management.
Who should be included on the HC team regarding pain management issues? Why – explain their roles
in pain management for the client.
7. Discuss current issues, trends and research related to pain management.
Outline the 7 concerns and fears about opioid use as discussed in the Murray textbook.
- Symbolism→ if he starts of morphine he will die
- Opioids are no longer use in a person’s last day
- Now use much earlier in the disease process
- Among ppl who receive opioids to manage pain, many reported improved quality of life and some
lived longer than ppl who did not received opioids
-
Postponing use of opioid until later→ If I take morphine now, what will I take when the pain
gets worth?
The dose of the morphine can be increased
There is no ceiling on the amount of pain relief that opioids can supply
Tolerance→ what if I get used to morphine and it become ineffective
The opioids dose can be increased or different opioids can be used
Dependence→ will I become dependent on morphine if I take it everyday?
The opioid dose will reduce slowly to prevent withdrawal symptoms. This does not indicate an
addiction
Addiction→ I don’t want to turn into an addict (read more on Murray)
Addiction is a psychological issue
A person who is addicted has anovwewhekming preoccuption with taking more medication than
necessary
Diversion
It occurs when prescriptions for opioids, written for a person in pain, make their way to the illegal
market
Make sure to restore them in a secure and locked location
Ensure that the person is taking and receiving the opioids prescribed
HCP’s fears about opioids
Addressing the fear/myths
-
Side effects –manageable and/or self-limiting
Symbolism– thinking “getting worse” but actually opioids are more useful in early stages of disease
process
Delirium– studies have shown the pain experience (e.g. stress, illness) is actually more of an
indicator of delirium than side effects from medication!!
Addiction– when medications are therapeutically used for treatment of pain, this is VERY RARE!!
8. Identify best practices for relieving symptoms using pharmacological and nonpharmacological nursing interventions to manage pain.
- Pharmacology– know the WHO Step Ladder Approach: This approach also emphasizes
administering analgesics by the clock, rather than on demand, to maintain comfort.
-
Non-pharmacological intervention
Physical
- Massage
- Heat/cold applications
- Immobilization
- TENS
- acupuncture
Cognitive behaviours
-
Distraction
Relaxation response
Psychoeducation
Preventing (Murray , p. 181)
-
Create a relaxing pace for daily activities
Position for comfort
Turn position in stages through the night
IN the moment (Murray , p. 181)
-
Distract the person for comfortable
Encourage relaxation for comfortable- massage,
breathing, imagery
Stimulate for comfort- frozen compress, creamy lotions,
gentle massage
With the family
Provide wheelchair massage
Holds and snuggle
9. Discuss the lived experience of a client living with acute and/or chronic pain.
Pain:
- One of the most common problems we face as health care providers
- One of the most significant fears that people express
- An unpleasant sensory and emotional experience associated with actual or potential tissue damage
-Whatever the person says it is and exists whenever the person says it does
Types of pain– define & give an example for each type:
Acute pain: a sudden onset, is usually self-limited, and is localized. The cause of acute pain generally
can be identified
Chronic pain: prolonged pain, or pain that persists after the condition causing it has resolved.
Although the cause may be identifiable (e.g., arthritis, cancer, migraine headache, diabetic
neuropathy), chronic pain does not always have an identifiable cause.
a. Nociceptive- damage to soft tissues and bones
Normalprocessing of stimuli
Can be explained/known etiology
- musculosckeletal→ sharp or dull ache eg. bne tumor, arthritis
- Somatic→ sharp eg. mouth sore, muscle aches
Visceral→deep ache or cramping that come and go in visceral organs
e.g. toothache, shingles, kidney stones, childbirth
Descriptive word (Squeezing, Tender, Pinching, Aching, Pounding, Throbbing, Sharp)
b. Neuropathic- Abnormal signal processing in peripheral or CNS
May be unexplainable or hard to identify etiology
Lesion or dysfunction in the nervous system
e.g. post-herpetic pain, diabetic neuropathy, phantom pain
Descriptive word ( Burning, Zinging, Tingling, Zapping, Numb, Drilling,Pins and Needles)
Origin
- visceral: arises from body organs. Visceral pain is dull and poorly localized because of the low
number of nociceptors. The viscera are sensitive to stretching, inflammation, and ischemia but
relatively insensitive to cutting and temperature extremes.
- Cutaneous and somatic: may be either sharp and well localized, or dull and diffuse.
Location
- referred : perceived in an area distant from the site of the stimuli.
- Radiating: pain that is perceived at the source of the pain and extends to nearby tissues
example is cardiac pain that is felt in the arm
Neuropathic: arises as a consequence of a lesion or visceral pain
- Phantom: type of neuropathic pain that occur after amputation- Phantom sensations, the feeling
that a lost body part is present, occur in most people after amputation. It is important for the nurse
to remember to explain the reasons for phantom limb pain, as clients may have difficulty
understanding why they have pain when the limb is gone.
Intractable: Severe pain that is incurable; causes death if not treated
- Pain syndrome: Complex regional pain syndromes (CRPS) cause extremity pain that is severe,
diffuse, and burning. The pain is accompanied by vasomotor changes that affect skin color and
temperature. Initially the affected extremity has typical inflammatory symptoms, with redness,
warmth, and swelling. Later, it is cool, cyanotic, and edematous; skin and nail changes may be seen.
The cause of CRPS is unclear; there may, in fact, be several causes, including damage to the central
or peripheral nervous system, or a disrupted healing or immune process. In CRPS, pain receptors in
the affected part of the body become sensitized to catecholamines, neurotransmitters associated
with sympathetic nervous system activity.
Nature
-
-
-
Acute: has sudden onset, is usually self-limited, and is localized. The cause of acute pain generally
can be identified (“I tripped and twisted my ankle; now it really hurts”). The onset is usually
sudden, most often resulting from trauma, surgery, or inflammation. The pain is usually sharp and
localized, although it may radiate. Tissue healing relieves pain. There are 3 major types of acute
pain: cutaneous and deep somatic pain, visceral pain, and referred pain.
Chronic: is prolonged pain, or pain that persists after the condition causing it has resolved.
Although the cause may be identifiable (e.g., arthritis, cancer, migraine headache, diabetic
neuropathy), chronic pain does not always have an identifiable cause. In some cases, pain may be
perpetuated by disease- caused damage that persists after the disease has resolved (e.g., sensory
nerve damage or reflex muscle contraction).
Breakthrough: pain that exceeds baseline chronic or persistent pain. It is often described as a
sudden flare that exceeds the analgesic effect of long-acting pain medications
Differentiate: (review PATH122!!!)
pain threshold
pain sensation
pain reaction
pain tolerance
10.Using a case study, apply the nursing process, including establishing priorities in nursing
care, to develop a care plan for a client living with acute and/or chronic pain.
HOMEWORK: **Review Case Study #30 in Kozier 3rded. p. 773 or Kozier 4thed. P. 704
-complete a data/analysis and care plan with one priority nursing diagnosis before coming to class
-Which Needs Guide(s) do you think is/are applicable?
-you will be sharing your work with others in the class (including the teacher) – please come prepared!
Read Case studies in Murray Ch. 5. P. 180-181 and 185-186.
What are the different issues in comparing the Kozier case study to the Murray case studies?
How are the approaches to nursing care different in these scenarios?
11.Explore the nursing implications for the administration of:
•Opioid analgesics
•Non-opioid analgesics
•NSAIDS
•Salicylates
•Acetaminophen
•Adjuvant medications
Come to class prepared to role play a teaching experience with your peers regarding analgesics!
(Helpful hint to learn about analgesics: Create a chart with the above analgesia headings –
compare assessment, therapeutic uses, what to teach a client about the drug, common side
effects, other information(e.g. alerts/cautions) and nursing actions for each. How do they
differ and what do they have in common?)
12. Medication
-
Is one set of tools for pain management
Combination of medications is often needed for best control
Analgesics– primary purpose is for pain relief (follow stepwise approach)
Adjuvant– primary use is not for pain relief, but pain relief occurs (may be called co-analgesics)
-
Sedation, constipation, nausea, and dizziness are common side effects of opioid analgesics
Non-opioids – first line of treatment for mild to moderate pain
-
-
All have a ceiling effect (after maximum dose, no further pain relief is expected)
Use caution and ↓ dose if
Infant, child or older adult
Renal or hepatic impairment
History of gastric bleed
EXAMPLES: acetaminophen (max 4g/24 hours), salicylates (ASA), ibuprofen
Nursing Responsibilities for non-opioid analgesic lemore, p,162
Do not administer aspirin with other NSAIDs.
Assess and document if the patient is taking a hypoglycemic agent or insulin; the NSAIDs may
increase the hypoglycemic effect.
Administer with meals, milk, or a full glass of water to decrease gastric irritation.
Assess patients who are also taking anticoagulants for bleeding; the NSAIDs increase this risk.
Health Education for the Patient and Family for non-opioid analgesic (lemore, p,162)
Drugs may cause gastrointestinal bleeding (report nausea, vomiting of blood, dark stools), visual
disturbances (report blurred or diminished vision), increased blood pressure, hearing problems,
dizziness, skin rash, and kidney problems (report weight gain or edema).
Take medications with meals to decrease gastric irritation.
Avoid drinking alcohol or taking any over-the-counter druG unless
approved by the healthcare provider.
The desired effects may not appear for 3–5 days, and the full effects may not appear for 2–4 weeks.
Maintain regular healthcare appointments
Acetaminophen
Acetaminophen is quite safe, and adverse effects are uncommon at therapeutic doses.
-
-
Unlike ASA, acetaminophen has no direct anti-inflammatory effect and does not affect blood
coagulation or cause gastric irritation. note that hepatotoxicity can occur with misuse and
overdose
It is not recommended in clients who are malnourished. In such cases, acute toxicity may result,
leading to renal failure, which can be fatal. Other signs of acute toxicity include nausea, vomiting,
chills, and abdominal discomfort.
Opioid- for moderate to severe pain relief ex.morphine, codein, oxycodone, Narcan, Talwin
-
-
-
Most effective when given on a regular scheduled basis to prevent pain from reoccurring
Dose levels can increase as pain relief needed (no ceiling effect)
Common side effects include:
Constipation
Nausea/vomiting
confusion
Drowsiness
Pruritus, Urinary retention, dry mouth, diaphoresis
Responding to opioid crisis
A complex current issue in our society which needs further exploration in future studies.
Opioids are regulated by federal law; the nurse must record the date, time, patient name, type and
amount of the drug used, and sign the entry in a narcotic inventory sheet or use an automated
medication dispensing device such as Pyxis. If the drug must be wasted after it is signed out, the act
must be witnessed and the nurse and the witness must both document. Computerized narcotic
documentation methods are frequently integrated into the electronic health system documentation
system.
Keep an opioid antagonist, such as naloxone, immediately available to treat respiratory depression.
Assess allergies or adverse effects from opioids previously experienced by the patient
Assess for respiratory disorders (e.g., asthma or COPD), neuromuscular disorders (e.g., multiple
sclerosis), and other conditions that might increase the risk associated with respiratory depression.
Assess the characteristics of the pain and the effectiveness of drugs that have been previously used
to treat the pain.
Take and record baseline vital signs before administering the drug.
Administer the drugs, following established guidelines.
Monitor vital signs and respiratory status, level of consciousness, papillary response, nausea, bowel
function, urinary function, and effectiveness of pain management at regular intervals and as
indicated.
Provide for patient safety.
Report adverse effects such as continued nausea, vomiting, or itching.
Employ protocols or prn orders as needed to promote bowel function and prevent constipation.
Meperidine (Demerol) is associated with CNS toxicity and thus involves significant patient risk
(Pasero, Quinn, et al., 2011).
Monitor any patient who is receiving more than one dose for nervousness, restlessness, tremors,
twitching, shakiness, myoclonic jerks, diaphoresis, changes in level of awareness, agitation,
disorientation, confusion, delirium, hallucinations, violent shivering, and/or seizures. Toxicity can
occur with any route of administration or any dosing regimen. The risk is increased in patients with
-
decreased renal function (including normal changes with aging). Report these manifestations to the
physician. Oral administration is not recommended.
Teach noninvasive methods of pain management for use in conjunction with opioid analgesics.
Adverse Effects kozier, p.693
●
●
●
●
●
●
●
-
respiratory depression
sedation – note that sedation may be a desired or an adverse effect
nausea, vomiting
potential to cause physical and psychological dependence, especially if high doses are taken for
extended periods of time
Itchiness
Urinary retention
Constipation
Health Education for the Patient and Family
The use of opioid analgesics to treat severe pain is unlikely to cause addiction
Do not drink alcohol while taking these drugs.
Do not take over-the-counter medications unless approved by the healthcare provider.
Increase intake of fluids and fiber in the diet to prevent constipation. Contact your provider if
additional measures (such as laxatives) are needed to manage constipation.
The drugs often cause dizziness, drowsiness, and impaired thinking; use caution when driving or
making decisions.
Report adverse effects or decreasing effectiveness to the physician.
Read assessment_and_Management_of_Pain_in_the_Elderly document under week 7
Route of medication
Topical medications work directly at the point of application on the body. They are
useful for painful procedures such as lumbar punctures or bone marrow
biopsies, or for injections. These products can also offer effective pain relief for
chronic pain syndromes such as low back pain.
The rectal route is useful for clients who have difficulty swallowing, or nausea
and vomiting.
The sublingual route is helpful for breakthrough pain because the oral mucosa is
well vascularized, which facilitates rapid absorption.
The transdermal approach delivers a relatively stable plasma drug level, and is
noninvasive. The medication, however, is systemic, which might not be what is
necessary for the client with chronic low back pain syndrome. Skin patch is the
example
Week 8
Review
2 type of wound healing
3 phases of healing
primary intention healing
secondary retention healing
inflammatory- Wound drainage (exudate) results from the
inflammatory process
during initial wound healing.
proliferative- begins within 2 to 3 days after surgery. Sutures
or staples are removed during this phase of wound
healing.
maturation
3 types of drainage/exudate - Serous drainage contains mostly the clear serous portion of
the blood. The drainage appears clear or slightly yellow and is
thin in consistency. Transparent (see through)- can be use for
sign dehydration
- Sanguineous drainage contains both serum and red blood
cells and has a thick, reddish appearance. This is the most
common type of drainage from an uncomplicated surgical
wound. black and serous fluid
- Purulent drainage is composed of white blood cells, tissue
debris, and bacteria. Purulent drainage results from infection.
Its consistency is greater than that of serous or sanguineous
drainage, and the color and odor vary by infecting organism.
yellow/ white
• No exudate: Wound bed is dry, and dressing is dry
• Scant: Wound bed is moist, but dressing remains dry
• Light/small: Wound bed is moist, and dressing is less
than 25% saturated in 3 days
• Moderate: Wound bed is moist, and dressing is 25% to
75% saturated in 3 days
• Large: Wound bed is moist, and dressing is more than
75% saturated in less than 3 days
3 wound complications
• Heavy: Wound bed is wet, and dressing is saturated in
less than 1 day
primary- when wound is uncomplicated and clean and has little
tissue loss- heal quickly, very little scare is expected. The
edges of the incision are well approximated (have come
together well) with sutures, staples, or superglue. This type of
surgical incision heals quickly, and very little scarring is
expected.
secondary – when wound is large, gaping, irregular. Tissue lost
prevents wound edge from approximating- takes time to heal,
more prone to infection
tertiary – also called delay primary intention healing. Wounds
that are left open for 3 to 5 days to allow edema or infection to
resolve or exudate to drain and are then closed with sutures,
staples, or adhesive skin closures heal by tertiary intention
healing.
NOTE:
- Controlling postoperative pain not only promotes comfort but also facilitates coughing, turning,
deep-breathing exercises, earlier ambulation, and decreased length of hospitalization, resulting in
fewer postoperative complications and therefore reducing healthcare costs.
- Relaxation, music, distraction, and imagery techniques can decrease mild pain and anxiety. Massage
and the application of heat or cold can also relieve postoperative pain. Transcutaneous electrical
nerve stimulation (TENS) has been used successfully to decrease postoperative incisional pain.
Other approaches include acupuncture, acupressure, and therapeutic touch.
Stage of pressure ulcer
1. Stage 1:A sign of risk. Intact skin with nonblanchable redness of a localized area, usually over a
bony prominence. The area may be painful, firm, soft, warmer, or cooler than adjacent tissue. May
be difficult to detect in people with dark skin.
2. Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red or pink
wound bed. May also present as an intact or open blister. The ulcer may be shiny or dry, without
bruising or slough (loss of tissue). •changes in one or more of the following: skin temperature ,
tissue consistency , and/or sensation.
3. Stage 3: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle
is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include
undermining and tunneling.
4. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to
muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus
tracts also may be associated with Stage IV pressure ulcers.
For DM staging based on neuropathy, deformity, vascularity and infection
5. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss: Full-thickness skin
and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it
is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury
will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an
ischemic limb or the heel(s) should not be removed. Mechanical debridement is the name of the
surgery to remove the eschar
Type of wound
o
o
o
o
o
o
Red-pink: salmon color, granulation tissue, firm and moist
intervention: cover and protect, stage 1, use transparent film
Pink- purple: repithelialization on the edges or around the hair follicle
Yellow
fibrous, could be firm or sloughy
Firm: underlying deep structures including fascia, fat or fibrin does not need to be removed
Sloughy: soft yellow base could be infection or degraded fibrin and needs to be removed
intervention: clean with cleansers
Black: Eschar, devitalized tissue needs to be removed if “heal-ability” has been established
intervention: 1. mechanical debridement (surgery), 2. when we use packing and packing gets dry
and we pull it out 3. enzyme 4. autolytic 5.chemical
1. Identify ten (10) risk factors for pressure injury development.
-
Developmental state / age
Nutrition
Life Style
Medications
Health status (especially vascular supply to wound bed/location)
Environment
2. Discuss the use of the Braden Scale for Predicting Pressure Ulcer Risk as a risk assessment
tool in nursing practice. (use to determine patient risk for ulcer)
components: score from 1-4 to provide a quality care
Before using this scale the nurse Should receive specific training
- sensory perception : ppl with dementia, stroke
- moisture: poor moisture
- activity : low daily activity
- mobility: (lack of purposeful movement)
- nutrition : low fluid
- friction and shear: bed sheet
Risk assessment score
- Low risk = ≥ 15
- Moderate risk = 13-14
High risk = ≤ 12
The total Braden Scores can range from 6 to 23.
- As a Braden scales scores become lower, predicted risk for developing the pressure ulcers become
higher.
- Patient within the range of 15 to 18 is at risk
- Patient within the range of 13 to 14 is at moderate risk
- Patient within the range of 10 to 12 is at high risk and 9 or below is very high risk for developing
the pressure ulcer. these levels of risk may also be helpful in determining how aggressive
preventive efforts should be.
3. Discuss best practice guidelines related to the assessment, prevention and management of
pressure ulcers. powerpoint
Prevention
- While pressure injuries are not always preventable, they have become an indicator of quality care
and represent a possible source of legal liability.
- https://rnao.ca/bpg/guidelines/pressure-injuries
- It’s important to remember that all patients entering health care institutions like hospitals or
complex continuing care facilities are at risk for the development of pressure ulcers.
- Similarly, patients, coming into hospital with existing pressure ulcers are at further risk for the
development of new pressure ulcers or worsening of their ulcers.
- The Braden Tool- use in making clinical judgments or care decisions with respect to prevention and
treatment of ulcers. This tool or scale measures broad categories of risk factors that place
individuals at risk for skin breakdown. For each parameter the clinician is required to assign a
score from 1 to 4. The overall numerical score provides a guide to the individual’s degree of risk.
Assessment of the ulcer
- Staging: partial or full thickness/Staging system for pressure wounds
o staging of the ulcer
o clarifying whether the wound is in an inflammatory/exudative phase
o quantity (scant, moderate, copious)
characteristics (serous-serum, sanguinous-blood,purulent-infection or a combination)
odor- alert for clinician a sign of uncontrolled edema or infection
done using the National Pressure Ulcer Advisory Panel system(8) (Level of evidence III
Location: precise location on a body map or diagram
can be of help in determining cause
ex. ulcers on the medial shin above the malleolus are more likely to be venous, as this is the location
of maximal venous pressure when upright
o Note: Ulcers in areas that are not subject to significant pressure, friction or shear should not be
assumed to be pressure ulcers.
- Length: longest diameter (disposable measuring tapes)
- Width: right angle to diameter
- Depth: with probe in the deepest part of the wound(sterile surgical, sterile plastic probe, sterile
cotton- tipped)
- Base: Three major colors (black, yellow, red) and surrounding area
- Exudate: quantity, characteristics, odor
- Wound margin: callus, maceration, edema or erythema
Ongoing management issue:
- Pain
- Failure to improve
- Infection
- Complexity* - collaboration and consultation with RN when outcome of wound care is not stable
and/or predictable
assessment
- Practical approach to the management of pressure ulcers in older patients.
- Prevention and management of most common type of ulcer in older adults
- Clarifying the cause and contributing factors
Objective and Subjective:
- history of wound healing
- PUSH/Braden / Norton skin guide (see Kozier) – also see if your clinical
agency uses a Braden or Norton scale
- Any factors
- Any pain
physical- wound pictures
o
o
o
o
o
Where is the wound (location)
Odour – note the wound bed odour (not just the old dressing)
Ulcer category (staging)
Necrotic tissue(eschar, black)
Drainage (colour, consistency, amount)=exudate
Pain- (PQRSTAU)
Induration (hardness or softness surrounding tissue - edema), border of the
wound- document as induration along peri-wound area is red, engorged, and
swelling or soft
●
Induration: A firmness and tautness extending from the edge of the wound, indicating possible tissue damage. it
could indicate where undermining might occur
Colour of wound bed (red (stage 1), yellow (pus), black (necrosis) or
combination)
Tunneling (length and direction)
Undermining (length and direction – use clock references to describe)
Redness or other discolouration in surrounding skin (peri-wound)
Edge of skin (called peri-wound – assess for maceration), described as:
● Attached: Smooth transition between the wound base and the intact skin.
● Rolled: The wound base is no longer attached to the skin, and the
surrounding edge is slightly rolled under
● Erythema: Redness surrounding the wound edge. Measure the distance from
the edge of the wound. A small amount of erythema surrounding a new
wound can be an indication of inflammation, which is a normal step in wound
healing and resolves within 2 to 3 days.
● Maceration: White, fragile tissue indicating too much moisture present in the
wound or periwound area. It may have resulted from increased exudate,
inappropriate dressing selection, perspiration, urine, or water from a shower
or bathing. Macerated tissue is much more likely to break down, and the
cause should be identified and eliminated
● Edema: Swelling around the wound that can result from localized disruption
of the lymphatic system. Presence of edema can delay healing by obstructing
vascular flow to the wound bed
Size/Shape (length, width, depth)
Systemic
- temperature- fever
- malaise
- diaphoresis
Common assessment finding of an infected wound: pain; purulent, odorous
discharge and redness; warmth; tenderness; and edema around the edges of
the incision. Additionally the patient has fever and increase RR and PR
Assess the patient’s blood supply for heapability
- Assess colour, sensation, movement, warmth (CSMW)
- Arterial blood supply is the most important consideration….can you explain
why?
note: Other major causes are pressure ulcers in immobile or institutionalized
patients, arterial insufficiency ulcers, and diabetic ulcers. The assessment of
the ulcer and a good history and physical examination are the mainstays of
clarifying diagnosis.
Need to identify the etiology of skin ulcer- only focus on pressure ulcer
- Pressure ulcers- a result of intense and/or prolonged pressure or pressure in
combination with shear
- Venous ulcers- common type of chronic lower limb wound, result from
disease or disrupted function of the veins
- Arterial ulcers
- Diabetic foot ulcers
- Trauma (wheelchair, bedrails)
diagnosis
the most common cause of skin ulcers is likely venous insufficiency. The
likelihood of other causes depends greatly on patient population and clinical
setting.
Other major causes are pressure ulcers in immobile or institutionalized patients,
arterial insufficiency ulcers, and diabetic ulcers. The assessment of the ulcer
and a good history and physical examination are the mainstays of clarifying
diagnosis.
(depending on depth of wound)
Impaired skin integrity→ dermis, epidermis
Impaired Tissue Integrity → subcutaneous
Risk for infection
planning
implication
But will also include: pain, body image changes, anxiety, may be even knowledge
deficit
KOZIER, P.931
Goal – to restore skin integrity & prevent infection
- maintain skin integrity and to avoid potential associated risk
- demonstrated progressive wound healing and regain intact skin
- if the skin is unable to heal, the goal may be provide a palliative care of the
wound.
- protect the skin
Expected Outcome: Patient will be free of manifestations of infection.
For risk for Impaired Skin Integrity
- Patient will experience wound healing through primary intention as indicated
by progressive approximation of wound borders.
The nurse assumes a leading role in supporting the wound healing process,
providing emotional support to the patient, and teaching wound
care to the patient.
1.Support healing
- nutrition
- fluids
- positioning
- asepsis – see principles and practices of surgical asepsis– practise and
testing in Wound Lab (from PNUR125)
Prevent pressure ulcers- See Braden
- skin hygiene
- nutrition
- avoid trauma
Client teaching
Risk for infection (Lemore, p. 281)
• Assess the wound for specific manifestations of infection, including
purulent drainage, foul odor, and delayed healing. The normal
inflammatory response can indicate infection and, on occasion, mask
its presence.
• Evaluate complete blood counts for adequate WBC response.
Leukocytosis may indicate infection or healthy response to injury
and protection from infection. Immune-impaired patients may not
respond with increased WBCs; manifestations of inflammation may
be diminished in those individuals.
• Monitor vital signs at least every 4 hours. In response to the inflammatory
process the temperature rises, usually in the range of 37.2°C
(99°F) to 38.2°C (100.9°F). A temperature of 38.3°C (101.0°F) or
above indicates infection. Fever is usually accompanied by increased
heart and respiratory rates.
Apply dry or moist heat to the affected area for no longer than
20 minutes several times a day. Monitor the temperature closely
to prevent burns and further damage to the affected area. Heat
increases the circulation of blood to and from the inflamed tissue.
Time is limited to prevent burns.
• Provide and encourage fluid intake of 2500 mL/day as allowed.
Teach the purpose and importance of hydration to promote blood
flow and nutrient supply to the tissues and also dilution and removal
of waste products and heat from the body.
• Ensure adequate nutrition. Adequate nutrition enhances the function
and production of T cells and B cells, which are important in the
immune response.
• Use good hand hygiene techniques consistently. Hand hygiene removes
transient microorganisms and is the best mechanism to prevent
the spread of infection to a susceptible person.
• Use aseptic technique when providing wound care. Using sterile
gloves and aseptic technique helps prevent further contamination of
the wound and the spread of infection to other patients.
Nursing care include the following measures :
• Maintain medical asepsis (e.g., by using good hand hygiene technique)
and standard precautions.
• Observe aseptic technique during dressing changes and handling
of tubes and drains.
• Assess vital signs, especially temperature.
• Evaluate the characteristics of wound discharge (color, odor, and
amount).
• Assess the condition of the incision (approximation of the edges,
sutures, staples, or drains).
• Clean, irrigate, and pack the wound in the prescribed manner.
• Maintain the patient’s hydration and nutritional status.
• Culture the wound prior to beginning antibiotic therapy.
• Administer antibiotics and antipyretics as prescribed.
• Provide supportive measures to patient and family.
Risk for impaired skin integrity LEMORE, P. 423-424
- Minimize skin exposure to moisture due to incontinence, perspiration,
or wound drainage.
4. Distinguish between the therapeutic uses of selected types of wound care products.
HELPFUL STUDY HINT:
Develop FLASHCARDS with various wound care products labelled on one side and the
description of uses on the other!
View the videos on woundeducators.com. and identify the wound care supplies that are available in
your clinical setting.
- What are the 9 principles of establishing and maintaining a sterile field?
- Review the practices which are associated with each of the principles. You will be applying these
practices in lab and clinical. Kozier, p900
principle
practice
All objects used in a
- All articles are sterilized appropriately by dry or moist heat, chemicals, or
sterile field
radiation before use.
must be sterile.
- Sterile articles can be stored for only a prescribed time; after that, they are
considered unsterile.
- Always check a package containing a sterile object for intactness, dryness,
and expiration date. Any package that appears open, torn, punctured, or
wet is considered unsterile. Never assume an item is sterile; if in doubt,
consider the item unsterile.
-Storage areas should be clean, dry, off the floor, and away from sinks.
- Always check the chemical indicators of sterilization before using a package.
The indicator is often a tape used to fasten the package or contained
inside the package. The indicator changes colour during sterilization,
indicating that the contents have undergone a sterilization procedure. If
the colour change is not evident, the package is considered unsterile.
Commercially prepared sterile packages may not have indicators but are
marked with the word sterile.
Sterile objects become
- Handle sterile objects that will touch open wounds or enter body cavities
unsterile
only with sterile forceps or sterile gloved hands.
when touched by
- Discard or resterilize objects that come into contact with unsterile
unsterile
objects.
objects.
- Whenever the sterility of an object is questionable, assume the article is
unsterile.
Sterile items that are out - once left unattended, a sterile field is considered unsterile.
of
- Sterile objects are always kept in view. Nurses should not turn their backs
vision or below the waist
on a sterile field.
level of the nurse are
- Only the front part of a sterile gown (from the waist to the shoulder) and
considered unsterile.
5 cm above the elbows to the cuff of the sleeves are considered sterile.
- Always keep sterile gloved hands in sight and above waist level; touch
only objects that are sterile.
- Sterile draped tables are considered sterile only at surface level.
- Once a sterile field becomes unsterile, it must be set up again before
proceeding.
Sterile objects can
- Keep doors closed and traffic to a minimum in areas where a sterile
become unsterile by
procedure is being performed; moving air can carry dust and
prolonged exposure to
microorganisms.
airborne dust containing - Keep areas in which sterile procedures are carried out as clean as
microorganisms.
possible by frequent damp cleaning with detergent germicides to
minimize contaminants in the area.
- Keep hair clean and short, tied back, or enclosed in a net to prevent hair
from falling on sterile objects. Microorganisms on the hair can make a
sterile field unsterile.
- Wear surgical caps in operating rooms, delivery rooms, and burn units.
-
Fluids flow in the
direction
of gravity.
-
Moisture that passes
through
a sterile object draws
microorganisms
from unsterile
surfaces above or below
to the sterile surface by
capillary action.
-
The edges of a sterile
field are considered
unsterile.
-
Skin is unsterile and
cannot be
sterilized.
-
-
-
Conscientiousness,
alertness,
and honesty are essential qualities in maintaining
surgical asepsis.
-
Refrain from sneezing or coughing over a sterile field. This can render the
field unsterile because of the spray of droplets containing
microorganisms from the respiratory tract. Some procedures require that
masks covering the mouth and the nose be worn when working over a
sterile field or an open wound.
Nurses with mild upper respiratory tract infections should refrain from
carrying out sterile procedures or should wear masks.
When working over a sterile field, talking should be kept to a minimum.
Turn the head from the field if talking is necessary.
To prevent microorganisms from falling over a sterile field, refrain from
reaching over a sterile field, unless sterile gloves are worn, and refrain
from moving unsterile objects over a sterile field.
Hold instruments with the tips below the handles. When the tips are held
higher than the handles, fluid can flow onto the handle and become
contaminated by the hands. When the forceps are again pointed
downward, the fluid flows back down and contaminates the tips.
When performing surgical hand hygiene, hold your hands higher than
your elbows to prevent contaminants from the forearms from reaching
the hands.
Sterile moisture-proof barriers are used beneath sterile objects. Liquids
(sterile saline or antiseptics) are frequently poured into containers on a
sterile field. If they are spilled onto the sterile field, the barrier keeps the
liquid from seeping beneath it.
Keep the sterile covers on sterile equipment dry. Damp surfaces can
attract microorganisms in the dust in the air.
Replace sterile drapes that do not have a sterile barrier underneath when
they become moist.
A 2.5-cm margin at each edge of an opened drape is considered unsterile
because the edges are in contact with unsterile surfaces.
Place all sterile objects more than 2.5 cm inside the edges of a sterile field.
Any article that falls outside the edges of a sterile field is considered
unsterile.
Use sterile gloves or sterile forceps to handle sterile items.
Prior to a surgical aseptic procedure, perform appropriate hand hygiene
to reduce the number of microorganisms on them.
When a sterile object becomes unsterile, it does not necessarily change in
appearance.
The person who sees a sterile object become contaminated must correct
or report the situation
Do not set up a sterile field ahead of time for future use.
Consider:
● When dropping commercially packaged sterile gauze onto an established sterile field, the gauze
lands with one corner almost off the edge of the field. Does this present any concerns regarding its
sterility? Explain.
How would you handle this situation?
●
After establishing a sterile field and applying sterile gloves, you realize that you have forgotten to
open the bottle of saline that needs to be poured into the dressing tray. The bottle is not sterile on
the outside. What are 2 ways you could solve this dilemma?
5. Discuss the factors to consider in wound care and choosing an appropriate wound care
product. Refer to RNAO BPG (Assessment & Management of Stage I to IV Pressure Ulcers) p. 98
Dressing choices – note purpose of each & when it would be used – will be taught more in lab
What dressing supplies are available in your clinical placement?
What dressing/wound care supplies would you use to treat:
o A skin tear?
o An incision draining small serous drainage?
o A stage 2 pressure ulcer with purulent exudate?
o A black necrotic heel ulcer?
o A reddened coccyx with non-blanchable erythema?
Heat & Cold – review notes from inflammation / fever class
Immobilization –
Types & uses for the different bandages:
- compression bandages: management for lower leg edema
- binders: support large area of the body such as abd, arm, chest . ex. triangle sling
Choice of dressing
- Continuous moist of wound environment accelerates healing by 50%
- Keep the surrounding dry, keep the ulcer bed moist
- Triangle shaped dressing for peri anal lesions
- Eliminate dead space by loosely packing with dressing material
- Ca-alginate (Kaltostat) from sea weed best for homeostasis and infection
- Hydrogels (Intrasite gel) for dry- sloughy wound
- Transparent films- stage 1
- Absorbent antibacterial( Cadexomer)
- Silver based dressing (e.g. Acticoat)
The aim of dressings is to help provide the optimal environment for wound healing. The dressing used
depends on the needs of the individual patient and the goal of the particular dressing. The most
important concept with dressing choice is the aim of keeping the wound moist. (Level of evidence I)
This represents a major shift from the past, where efforts focused on drying out a wound by
dressings and mechanical means. Moist wound healing has been shown to improve reepithelialization and decrease infection rates. It is important to note that wounds with excessive
exudate can become macerated, hence dressing choice may be dictated by a large amount of
drainage.
Dressings may be occlusive such as the hydrocolloids, or non-occlusive such as wet-saline dressings.
Occlusive dressings are generally used when there is a good granulation base as this will increase
epithelialization and protect the healing tissue from trauma. Collaborative discussions are very
important in developing a feasible and effective strategy for dressing applications.
use for: stage 1
Transparent Film: Opsite, Tegaderm
- thin, flexible, sheet, clear, elastic
dry wound
- Moisture retentive and does not absorb
outcome: maintain a moist environment, promotes epithelialization, help
minor burn
to protect bacterial contamination
use for: superficial partial thickness wound, secondary dressing, healing
skin tear
wound with limited drainage, prevent infection
- benefit: Protection of skin from stool/urine (waterproof) , you can assess
donor sites
the ulcer, “Get the pressure off!”, Decreasing shear and friction
use for:
moderate amount of
exudate
large amount of
exudate
partial or thickness
wound
infected wound
Dry ulcer (partial or
full thickness
for dry- sloughy
wound
Dry ulcer (partial or
full thickness)
moderate amount of
exudates
absorption
May tear surrounding skin, particularly in elderly
should not be used on infected wound, do not have absorptive properties
permeable to oxygen, water vapor, CO2 and impermeable to water and
bacteria
dressing must be changed if it leaks
note: not appropriate for yellow wound
Foam Dressing: Allevyn hydrocellular, Hydrasorb, Curafoam, mepilex
- Absorption of exudate in superficial or deep wounds
- outcome: absorbs large amount of exudate, maintain moisture, removes
exudate from wound surface, protect the surrounding skin from
maceration, confirm to body shape, provide protection and cushioning
- disadvantages: may potentially ry wound surface
- Prolong interval/frequency of dressing changes
- Usually need a secondary dressing to retain foam
- Can be left for up to 7 days
- heart shape
Alginates: Kaltostat, Algisite, Curasorb
- highly absorbent, may be in sheet or rope form
Absorption of exudate (large amount)
- May be used in exudating wounds with granulation tissue and be helpful
for maceration of skin
- Require a secondary dressing
Usually changed daily, may dry out wound bed if there is not enough
wound fluid
- can be easily removed by irrigation
- control exudate and maceration
Hydrogels: Intrasite Gel, Duoderm Gel, normlgel
- available in sheet, gel, and impregnated gauze form
- outcome: Creation or maintenance of moist wound environment (but not
absorb any), can be used in all phases of wound healing, relieve pain
- necrotic wound requiring a Autolytic debridement
- should not be used to fill dead space
- Packing for dry deep cavity wounds
Requires secondary dressing
- May be difficult to keep in place with superficial wound
- usually changed OD or BID
- may cause burning sensation
Wet Saline Gauze Dressings
Creation or maintenance of moist wound environment in wounds with
minimal or no granulation tissue
Need to be changed frequently to avoid drying to the ulcer and damaging
viable tissue
- Wetness may macerate surrounding skin
- Usually changed OD or BID
Hydrocolloids: Duoderm, Tegasorb, Comfeel
Non- infected granulation or epithelializing ulcer
pressure ulcer- stage
1 and 2
minor burn
Outcome: Moist wound healing in ulcer with granulation tissue, aid in
autolytic debridement, minimizes pain and trauma to wound base,
protects wound base from bacteria
- Change every 5-7 days, change if leakage occurs
- Avoid in infected wounds or those with heavy exudate (bleeeding), dry
wounds
- May be difficult to maintain over sacrum or buttocks
- May injure surrounding skin when removed, only use for patients with
good skin integrity
Hydrofiber (such as Aquacel)
- available in rope or sheet form, highly absorbent
- moisture
- no exudate, at risk for bleeding, may dry out wound bed if there is not
enough wound fluid
- can be used with actual or at risk for infection
- control exudate and maceration
skin barrier: skin prep
- protect peri-wound area
6. Discuss current issues, trends and research related to prevention and treatment of
wounds, and/or pressure ulcers.Review the Canadian Association of Wound Care: Quick Reference
Guide in
There are 5 steps in the Wound Prevention and Management Cycle. Kozier 4th ed. P. 974-975
PowerPoint
The prevention and treatment of skin ulcers involves awareness of risk factors and prompt
intervention with an evidence-based approach.
Here is some recommendation by National Pressure Ulcer Advisory Panel.:
Risk assessment:
- Consider all bed- or chair bound persons, to be at risk for pressure ulcer.
- Select and use a method of risk assessment, such as braden or norton scales that ensure systematic
evaluation of individual risk factors.
Skin care and early treatment:
- Inspect the skin at least once a day.
- Avoid hot water and use a mild cleansing agent during the bathing client.
- Use moisture for dry skin.
- Use dry lubricants( cornstarch) or protective coverings to reduce friction injury.
Mechanical loading and support:
- Reposition bed bound person at least every 2/hrs
- Use a written repositioning schedule.
- Use pressure reducing mattress, and chair cushion. Do not use donut- type devices.
- Use left devices to move rather than drag persons during transferring and position changes
Education:
- Implement educational programs for the prevention of pressure ulcers that are structured,
organized, comprehensive, and directed at all levels of heath care providers, patients , family and
caregivers.
7. Using a case study, apply the nursing process, including establishing priorities in
nursing care, to develop a care plan for the client with impaired skin or tissue integrity.
Complete Case study # 35 in Kozier et al. 3rd ed. pg. 1051. OR 4th ed. Pg. 978
●
●
●
●
●
Identify a priority need with rationale
Select 4 cues or clusters of relevant data from the case study and show the analysis of this data that
is focused to your Priority Need
Write one priority nursing diagnosis
Write two expected outcomes (SMART Goals)
Write 4 nursing interventions (how, what, and when)
PowerPoint:
82 yo ♂ BMI 17 lives alone admitted b/c of CVA.
Recent pneumonia secondary to prolonged immobility.
He has urinary incontinence and profound weakness of left side.
How would you assess the risk on admission?
What would be your prevention plan?
What steps should you take to promote healing?
- 1/ The risk, his age, build, immobility, incontinence
- 2/Control of incontinence (condom catheterization) frequent turning and inspection, using
specialized bed. High staff to pt ratio.
- 3/local measures: preparing the wound bed, Cleans the wound, debride dead tissues, control any
inf. Irrigation the cavity with normal saline. Filled the cavity with dressing material(
Hydrogel,Hydrocolloid paste)
- Heal wound with continuing the wound moist/ consider plastic Sx.
- General measurers: Relieve Pt with good nursing practice such as regular turning, dealing with
disability ,intensive physiotx, nutrition – protein intake and fluids.
8. Explore the nursing implications for the administration of anticoagulant therapy:
anticoagulants- Inhibit platelet action, prevent thrombi growth
– Prevent thrombi from forming or enlarging
– Prototype drugs: heparin (parenteral) and warfarin (oral)
– Mechanism of action: to inhibit specific clotting factors to prevent formation or enlargement of
clots
– Primary use: to prevent formation of clots in veins, to treat thromboembolic disorders
– Role of nurse
– Most serious side effect to assess is bleeding
– To assess internal bleeding
– Monitor CBC, lumbar pain, abdominal bulging, guaiac tests on stool
– Essential for patient safety to assess coagulation studies
– Bleeding risk increases during transition from heparin to warfarin
– Do not give warfarin to pregnant patients
– Heparin, low–molecular weight heparin can be given to pregnant patients
– Monitor intake of vitamin K–rich foods (this does not mean avoid this – this means to know the
intake and keep consistent in diet); limit intake of garlic
platelet inhibitors- Inhibit clotting factors, prevent thrombus grow
– Prolong bleeding time by interfering with aggregation of platelets
– Mechanism of action: to alter the plasma membrane of platelets so they cannot aggregate
– Primary use: to prevent thrombi formation after stroke or myocardial infarction
– Include (testable in PNUR124)
– Acetylsalicylic acid*
– Adenosine diphosphate (ADP) receptor blockers*
– These drugs will not be tested in PNUR124:
– Glycoprotein 11b/111a receptor antagonists
–
–
–
–
–
–
–
Drugs for intermittent claudication
Role of the nurse:
Monitor for bleeding
Risk increases if given with anticoagulants
Prolonged pressure needed to control bleeding at puncture sites
Monitor for gastrointestinal upset with warfarin and ticlopidine (Ticlid)
May increase menstrual bleeding
Note:
Identification of exacerbating factors
- Ongoing pressure/ friction
- Local edema (e.g. venous insufficiency, heart failure)
- Anemia
- Arterial insufficiency
- Poor diabetic control
- Chronic steroid use (oral or topical)
- Smoking
- Micro and macronutrient deficiency (e.g. protein, dehydration)
- Presence of fecal and urinary incontinence
Particularly in elderly patients, exacerbating factors interact with the precipitating cause to worsen an
ulcer or to slow healing. (Level of evidence III) The role of aging alone versus medical issues
common in aging is uncertain. Important healing factors
Adequate cleaning and debridement
- Cleaning
- Surgical
- Autolytic
- Enzymatic
- Mechanical
- A commonly used adage about cleansing wounds is to “never put anything in a wound that you
wouldn’t put in your eye!” This is because many disinfectants are tissue toxic and may injure
healing wounds, particularly those with granulation tissue. (Level of evidence II).
- The recommended cleaning solutions are sterile water and sterile saline. (Level of evidence III)
- Topical antibiotics are not recommended for prophylaxis in a healing, asymptomatic wound.
- Most of the guidelines provide specific recommendations for the optimal way to irrigate and clean a
wound. Staff should irrigate with 100-150 ml of room temperature solution (Level of evidence II)
- using enough pressure to clean the wound without injuring the wound bed. This may be done by
using a single-use 100ml saline squeeze bottle or a 35-ml syringe with a 19-gauge angiocath. (Level
of evidence II)
- Adequate debridement of ulcers is important to promote wound healing and to decrease the risk of
infection. The main options for debridement are sharp (surgical), autolytic, enzymatic, and
mechanical. Surgical debridement is the mode most familiar to family physicians and is a skill that
can be used in the office, hospital or LTC setting for most ulcers. Some significant Stage 3-4 ulcers
may require aggressive debridement in the operating room. There are few options for learning the
skills formally but working with an experienced colleague or with a local surgeon can provide the
necessary experience. Equipment should be sterile (Level of evidence II) and include a scalpel,
scissors, and toothed forceps (not the plastic forceps provided in most dressing trays). Analgesia
can be provided by short-acting oral analgesics, by topical agents(10,11) or local anesthetic
injection. More extensive debridement may require specific nerve or regional blocks, however.
Infection is an indication for surgical debridement as eschar provides an ideal medium for bacteria.
(Level of evidence I) Contraindications to surgical debridement are important to recognize and
include significant arterial insufficiency to the ulcer, protein malnutrition or other factors limiting
development of granulation tissue. Anticoagulation is a relative contraindication for sharp
debridement of full-thickness wounds. It should be noted that stable heel ulcers with a protective
eschar covering may be considered an exception to the recommendation that all eschar be
debrided.(12)
- Autolytic debridement involves the use of moisture retentive dressings such as gels (e.g., Intrasite),
hydrocolloid (e.g., Duoderm), film dressing (e.g., Opsite) and alginates (e.g., Kaltostat) to soften up
hard eschar over a week or so. Enzymatic debridement agents break down collagen in the eschar.
Collagenase is the most commonly used preparation. Although it has a low risk of injuring local
healthy tissue, it should be discontinued once granulation tissue begins to form. Mechanical
debridements have little role in management and include so-called “wet to dry” dressings where a
gauze dressing is allowed to dry onto the wound and is then pulled off to remove the eschar. This
approach can be painful and may also damage viable tissue and slow healing.
Get the pressure off
- Collaborative approach
- Use of pressure reducing surfaces
- This approach is important in all ulcers but particularly in pressure ulcers. A collaborative
approach is required involving nursing, occupational therapists, physical therapists, enterostomal
therapists and sometimes administration to obtain potentially costly treatment options (Level of
evidence III). The use of pressure reducing surfaces such as high specification foam mattresses is
recommended for all patients at high risk for ulcer development and those with existing ulcers
(Level of evidence I).
- “Getting the pressure off” also relates to venous ulcers, as it is high venous system pressures that
cause these ulcers. In the last few years, several protocols have been developed and are being used
by several Ontario home care programs to aggressively treat venous ulcers with high compression
dressings. There is Level I evidence that multi-layer, high compression dressing are more effective
than single layer or low compression choices.
-
not coming on the test
pharmacology (adam):
- Used for diagnosing and treating coagulation disorders
1.
a.
2.
a.
Anticoagulant
inhibit clotting factors, prevent thrombus growth
Antiplatelets
Inhibit platelet action, prevent thrombus growth
Anticoagulant
Mechanism of action: to inhibit specific clotting factors to prevent formation or
enlargement of clots
Primary
use: to prevent formation of clots in veins, to treat thromboembolic disorder
Coumadin- warfarin
heparin
teach:
• Immediately report burning, stinging, tightness, tenderness,
anticoagulant
warmth, or other pain at heparin injection or IV insertion sites;
these signs may signal drug infiltration into sensitive tissues.
• Notify the nurse of excessive bruising or evidence of swelling
at a heparin injection site.
• Take warfarin at the same time each day.
• Moderate daily intake of vitamin K–rich foods when taking
Warfarin. Green vegetable
• Avoid strenuous and hazardous activities that could result in
bleeding injury.
nurses role:
•Most serious side effect to assess is bleeding
•To assess internal bleeding
–Monitor CBC, lumbar pain, abdominal bulging, guaiac tests on stool
•Essential for patient safety to assess coagulation studies
•Bleeding risk increases during transition from heparin to warfarin
–Do not give warfarin to pregnant patients
–Heparin, low–molecular weight heparin can be given to pregnant patients
–Monitor intake of vitamin K–rich foods(this does not mean avoid this – this
means to know the intake and keep consistent in diet); limit intake of garlic
acetylsalicylic acid •Mechanism of action: to alter the plasma membrane of platelets so they
cannot aggregate
(ASA [Aspirin])
•Primary use: to prevent thrombi formation after stroke or myocardial
infarction
Adenosine
nurses role:
diphosphate (ADP)
•Monitor for bleeding
receptor blockers–Risk increases if given with anticoagulants
antiplatelet
•Prolonged pressure needed to control bleeding at puncture sites
•Monitor for gastrointestinal upset with warfarin and ticlopidine (Ticlid)
•May increase menstrual bleeding